Provider Demographics
NPI:1841843786
Name:LUOMA, MARDI LEE (MA, LPC, LAC)
Entity type:Individual
Prefix:MS
First Name:MARDI
Middle Name:LEE
Last Name:LUOMA
Suffix:
Gender:F
Credentials:MA, LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 MARINERS WAY
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3208
Mailing Address - Country:US
Mailing Address - Phone:843-291-2311
Mailing Address - Fax:
Practice Address - Street 1:506 SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2793
Practice Address - Country:US
Practice Address - Phone:843-291-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC305101YA0400X
SC6877101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)