Basic Information
Provider Information | |||||||||
NPI: | 1073092086 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ENTER | ||||||||
FirstName: | NATALIE | ||||||||
MiddleName: | JEANNETTE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ENTER | ||||||||
OtherFirstName: | NATALIE | ||||||||
OtherMiddleName: | JEANNETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2100 CHARLIE HALL BLVD | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294145832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438524100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2100 CHARLIE HALL BLVD | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 29414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438524100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2018 | ||||||||
LastUpdateDate: | 05/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | APC005968 | GA | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPC010690 | GA | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPC7470 | SC | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 82-0678191 | 01 | GA | 1619495389 | OTHER |