Provider Demographics
NPI:1902649346
Name:WEATHERFORD, KACIE GABRIELLE
Entity type:Individual
Prefix:MS
First Name:KACIE
Middle Name:GABRIELLE
Last Name:WEATHERFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 CURT CHAPMAN CIR
Mailing Address - Street 2:
Mailing Address - City:SOCIETY HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29593-5300
Mailing Address - Country:US
Mailing Address - Phone:843-601-5793
Mailing Address - Fax:
Practice Address - Street 1:346 CURT CHAPMAN CIR
Practice Address - Street 2:
Practice Address - City:SOCIETY HILL
Practice Address - State:SC
Practice Address - Zip Code:29593-5300
Practice Address - Country:US
Practice Address - Phone:843-601-5793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
SC106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst