Basic Information
| Provider Information | |||||||||
| NPI: | 1568083210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOTTEY | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 HALEY BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295266399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434464053 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1608 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295263572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432484700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2020 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 13131 | SC | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.