Provider Demographics
NPI:1780351395
Name:CHESTNUT, DEMETRIA
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:CHESTNUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 HOFFMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4015
Mailing Address - Country:US
Mailing Address - Phone:843-960-2050
Mailing Address - Fax:843-407-7743
Practice Address - Street 1:2147 HOFFMEYER RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4015
Practice Address - Country:US
Practice Address - Phone:843-960-2050
Practice Address - Fax:843-407-7743
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12350104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker