1265433411 NPI number — MRS. BRENDA SHARALYN FISHER MA, LCAS LPC LPC-S

Table of content: MRS. BRENDA SHARALYN FISHER MA, LCAS LPC LPC-S (NPI 1265433411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265433411 NPI number — MRS. BRENDA SHARALYN FISHER MA, LCAS LPC LPC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISHER
Provider First Name:
BRENDA
Provider Middle Name:
SHARALYN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, LCAS LPC LPC-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FISHER
Provider Other First Name:
BRENDA
Provider Other Middle Name:
SHARALYN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC LCAS LPC-S
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1265433411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
428 HAMILTON DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLIVIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28422-7716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-964-3352
Provider Business Mailing Address Fax Number:
910-842-3351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4320 SOUTHPORT SUPPLY RD SE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SOUTHPORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28461-8158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-964-3352
Provider Business Practice Location Address Fax Number:
910-842-3351
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  4124 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 340955 . This is a "MHN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 340955 . This is a "BC/BS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com