Provider Demographics
NPI:1801289822
Name:DUPONT, KATREVA (SOCIAL WORKER, LCSW)
Entity type:Individual
Prefix:
First Name:KATREVA
Middle Name:
Last Name:DUPONT
Suffix:
Gender:F
Credentials:SOCIAL WORKER, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BEE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-5703
Mailing Address - Country:US
Mailing Address - Phone:843-577-5011
Mailing Address - Fax:
Practice Address - Street 1:500 E OGLETHORPE HWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2804
Practice Address - Country:US
Practice Address - Phone:843-577-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57773104100000X
FLSW140851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker