Basic Information
Provider Information | |||||||||
NPI: | 1205995727 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUKES | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | SMEAD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, ATR-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMEAD | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | ANNA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 300 E MCBEE AVE FL 4 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296012842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645228603 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10 PATEWOOD DR STE 130 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296156317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644558988 | ||||||||
FaxNumber: | 8645225555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2006 | ||||||||
LastUpdateDate: | 05/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5266 | SC | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | PC1976 | 05 | SC |   | MEDICAID |