Healthcare Provider Details

I. General information

NPI: 1952694945
Provider Name (Legal Business Name): SELENA MARIA BROWN III INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 CARTER ST
COLUMBIA SC
29204-2811
US

IV. Provider business mailing address

1135 CARTER ST
COLUMBIA SC
29204-2811
US

V. Phone/Fax

Practice location:
  • Phone: 803-786-1183
  • Fax:
Mailing address:
  • Phone: 803-786-1183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: