Provider Demographics
NPI:1043908593
Name:STOCKBRIDGE, KAREN (EDS, LPES)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:STOCKBRIDGE
Suffix:
Gender:F
Credentials:EDS, LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 BACONS BRIDGE RD APT B12
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-3258
Mailing Address - Country:US
Mailing Address - Phone:703-508-4467
Mailing Address - Fax:
Practice Address - Street 1:1815 BACONS BRIDGE ROAD #B12
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-3258
Practice Address - Country:US
Practice Address - Phone:843-376-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool