Healthcare Provider Details

I. General information

NPI: 1659007250
Provider Name (Legal Business Name): BRANDY DAWN LEO-BACOME LISW CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRANDY DAWN LEO LISW CP

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 CLEVY BUSH DR
INMAN SC
29349-9489
US

IV. Provider business mailing address

318 CLEVY BUSH DR
INMAN SC
29349-9489
US

V. Phone/Fax

Practice location:
  • Phone: 904-322-2773
  • Fax:
Mailing address:
  • Phone: 904-322-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number14073
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18364
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: