Provider Demographics
NPI:1902951684
Name:WARDDUTTON, MIKKA (LPC)
Entity Type:Individual
Prefix:
First Name:MIKKA
Middle Name:
Last Name:WARDDUTTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MIKKA
Other - Middle Name:KELLY
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, LPC-S
Mailing Address - Street 1:1606 EDINBURGH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-1808
Mailing Address - Country:US
Mailing Address - Phone:843-263-1714
Mailing Address - Fax:843-263-1714
Practice Address - Street 1:80 LADYS ISLAND DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1643
Practice Address - Country:US
Practice Address - Phone:843-812-7199
Practice Address - Fax:843-986-0046
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4575101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC187076Medicare UPIN