Healthcare Provider Details

I. General information

NPI: 1811676992
Provider Name (Legal Business Name): BRENDA GAILE CISCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

696 N SPENCE AVE
GOLDSBORO NC
27534-4354
US

IV. Provider business mailing address

436 DOGWOOD TRL
GOLDSBORO NC
27534-8944
US

V. Phone/Fax

Practice location:
  • Phone: 919-330-4147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA18988
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: