Provider Demographics
NPI:1063835445
Name:COMMODORE, YVONNE ADASSA (EDD, EDS, LISW-C)
Entity type:Individual
Prefix:DR
First Name:YVONNE
Middle Name:ADASSA
Last Name:COMMODORE
Suffix:
Gender:F
Credentials:EDD, EDS, LISW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-0062
Mailing Address - Country:US
Mailing Address - Phone:803-321-6657
Mailing Address - Fax:
Practice Address - Street 1:4029 MCGEE RD
Practice Address - Street 2:
Practice Address - City:COWARD
Practice Address - State:SC
Practice Address - Zip Code:29530-5232
Practice Address - Country:US
Practice Address - Phone:843-767-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC188020101Y00000X, 101YM0800X, 104100000X, 1041S0200X
SC181531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool