Basic Information
| Provider Information | |||||||||
| NPI: | 1003013616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOSCHKOLUP | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | VALESKA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743294 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645161170 | ||||||||
| FaxNumber: | 8772499483 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 ROPER CREEK DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645161170 | ||||||||
| FaxNumber: | 8772499483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 29966 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 299661 | 05 | SC | MEDICAID |