Basic Information
| Provider Information | |||||||||
| NPI: | 1336399054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARNER | ||||||||
| FirstName: | TRACY | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435248899 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 FOREST DR | ||||||||
| Address2: | |||||||||
| City: | VARNVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299444886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039432828 | ||||||||
| FaxNumber: | 8039434568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1336399054 | 05 | SC | MEDICAID |