Healthcare Provider Details

I. General information

NPI: 1871353144
Provider Name (Legal Business Name): TRAYLOR DISBROW LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 GADSDEN ST STE 204
COLUMBIA SC
29201-6400
US

IV. Provider business mailing address

237 TOLBERT ST
LEXINGTON SC
29072-6621
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-9767
  • Fax:
Mailing address:
  • Phone: 803-767-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number8897
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: