Provider Demographics
NPI:1962055632
Name:UNDERWOOD, MAZIE SUNSHINE (MS, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:MAZIE
Middle Name:SUNSHINE
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 CLEMENTS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8322
Mailing Address - Country:US
Mailing Address - Phone:843-797-5050
Mailing Address - Fax:843-797-3633
Practice Address - Street 1:1951 CLEMENTS FERRY RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29492-8322
Practice Address - Country:US
Practice Address - Phone:843-797-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1906OtherSC DHEC