1407352016 NPI number — MRS. BREANNA ELDER SPARROW LCMHC

Table of content: MRS. BREANNA ELDER SPARROW LCMHC (NPI 1407352016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407352016 NPI number — MRS. BREANNA ELDER SPARROW LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARROW
Provider First Name:
BREANNA
Provider Middle Name:
ELDER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPARROW
Provider Other First Name:
BREANNA
Provider Other Middle Name:
CATHLEEN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407352016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
259 AZALEA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27105-1789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2499 HENNING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27106-4558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-291-7477
Provider Business Practice Location Address Fax Number:
336-217-8044
Provider Enumeration Date:
04/03/2018

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:  A13770 , 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)





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