Basic Information
| Provider Information | |||||||||
| NPI: | 1891743514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE HERDER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | FIELDS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR L CHT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FIELDS | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1483 TOBIAS GADSON BLVD | ||||||||
| Address2: | SUITE 205B | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437666494 | ||||||||
| FaxNumber: | 8437666495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1483 TOBIAS GADSON BLVD | ||||||||
| Address2: | SUITE 205B | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294074641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437666494 | ||||||||
| FaxNumber: | 8437666495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 06/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 000205 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | TH1008 | 05 | SC | MEDICAID |