Healthcare Provider Details

I. General information

NPI: 1639106511
Provider Name (Legal Business Name): DONNA WILLSON UPCHURCH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 1/2 CALHOUN ST
COLUMBIA SC
29201-2509
US

IV. Provider business mailing address

1401 1/2 CALHOUN ST
COLUMBIA SC
29201-2509
US

V. Phone/Fax

Practice location:
  • Phone: 803-252-1866
  • Fax: 803-252-1177
Mailing address:
  • Phone: 803-252-1866
  • Fax: 803-252-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR16029
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: