Provider Demographics
NPI:1154194884
Name:BERESFORD, KHABONINA JOY (LMSW)
Entity type:Individual
Prefix:
First Name:KHABONINA
Middle Name:JOY
Last Name:BERESFORD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-4102
Mailing Address - Country:US
Mailing Address - Phone:843-830-8835
Mailing Address - Fax:
Practice Address - Street 1:430 WOODRUFF RD STE 450
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3443
Practice Address - Country:US
Practice Address - Phone:864-400-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16257104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker