Healthcare Provider Details

I. General information

NPI: 1700073129
Provider Name (Legal Business Name): BRUCE KENDRICK LINDSEY LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2007
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 79TH AVE N
MYRTLE BEACH SC
29572-4310
US

IV. Provider business mailing address

764 WALNUT KNOLL LN
CORDOVA TN
38018-3113
US

V. Phone/Fax

Practice location:
  • Phone: 843-948-1191
  • Fax: 843-948-1192
Mailing address:
  • Phone: 901-756-5565
  • Fax: 901-756-5564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18275
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: