Healthcare Provider Details

I. General information

NPI: 1295971927
Provider Name (Legal Business Name): GLENDA GAIL BUMGARNER M.DIV., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 GROCE RD
LYMAN SC
29365-1761
US

IV. Provider business mailing address

84 GROCE RD
LYMAN SC
29365-1761
US

V. Phone/Fax

Practice location:
  • Phone: 864-439-7760
  • Fax:
Mailing address:
  • Phone: 864-439-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4480
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1164
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: