Basic Information
| Provider Information | |||||||||
| NPI: | 1265158604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEVRETTE | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | JAINE | ||||||||
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| Credential: | BS ADC-IP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 557 ABIGAIL ST | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294616870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487635653 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2470 MALL DR UNIT CD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294066514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432074721 | ||||||||
| FaxNumber: | 8472074727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2022 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.