Healthcare Provider Details

I. General information

NPI: 1699062109
Provider Name (Legal Business Name): KAYLA BROOKS BRUNSON SLP-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 BULL ST
COLUMBIA SC
29201-2560
US

IV. Provider business mailing address

1931 BULL ST
COLUMBIA SC
29201-2560
US

V. Phone/Fax

Practice location:
  • Phone: 803-767-4832
  • Fax:
Mailing address:
  • Phone: 803-767-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number4889
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: