Healthcare Provider Details

I. General information

NPI: 1467596486
Provider Name (Legal Business Name): ROBERT E DEYSACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1723 GLENWOOD RD
COLUMBIA SC
29204-7713
US

IV. Provider business mailing address

1723 GLENWOOD RD
COLUMBIA SC
29204-7713
US

V. Phone/Fax

Practice location:
  • Phone: 803-782-9807
  • Fax:
Mailing address:
  • Phone: 803-782-9807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number81
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: