Provider Demographics
NPI:1184863359
Name:MEDLEY, THERESA ANNE (LISW CP)
Entity type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:ANNE
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:LISW CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:5133 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6338
Practice Address - Country:US
Practice Address - Phone:843-789-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8561104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1420Medicaid