Basic Information
| Provider Information | |||||||||
| NPI: | 1518247394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISP | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | KAYE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295660547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436638000 | ||||||||
| FaxNumber: | 8436638166 | ||||||||
| Practice Location | |||||||||
| Address1: | 4303 LIVE OAK DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295669138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436638000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 7799 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 0701008164 | VA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 171W00000X | N | Other Service Providers | Contractor | 225800000X | 43287 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist |
ID Information
| ID | Type | State | Issuer | Description | PC2522 | 05 | SC | MEDICAID |