Healthcare Provider Details

I. General information

NPI: 1477538817
Provider Name (Legal Business Name): CLARE UNDERWOOD BRYAN MED NCC LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121A BELLEVUE RD
DUBLIN GA
31021-2998
US

IV. Provider business mailing address

2121A BELLEVUE RD
DUBLIN GA
31021-2998
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-1190
  • Fax: 478-275-6509
Mailing address:
  • Phone: 478-275-3546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC004142
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: