Provider Demographics
NPI:1265847255
Name:TRACY REDFEARN INC.
Entity type:Organization
Organization Name:TRACY REDFEARN INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHO EDUCATIONAL SPECIAL
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDFEARN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPES
Authorized Official - Phone:843-917-0495
Mailing Address - Street 1:702B W CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4412
Mailing Address - Country:US
Mailing Address - Phone:843-917-0495
Mailing Address - Fax:843-917-0495
Practice Address - Street 1:702B W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4412
Practice Address - Country:US
Practice Address - Phone:843-917-0495
Practice Address - Fax:843-917-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4605103TB0200X, 103TM1800X, 103TS0200X, 101YS0200X, 104100000X, 235Z00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4605OtherSTATE LPES LICENSE NUMBER
SCLP1000Medicaid