Healthcare Provider Details

I. General information

NPI: 1548074545
Provider Name (Legal Business Name): BRENTLEY SUE ELMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 FREELAND WAY
MONCKS CORNER SC
29461-8868
US

IV. Provider business mailing address

303 FREELAND WAY
MONCKS CORNER SC
29461-8868
US

V. Phone/Fax

Practice location:
  • Phone: 757-372-1731
  • Fax:
Mailing address:
  • Phone: 757-372-1731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10280
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: