=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265433411
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA SHARALYN FISHER MA, LCAS LPC LPC-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 09/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4320 SOUTHPORT SUPPLY RD SE SUITE 300
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-8158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-964-3352
-----------------------------------------------------
Fax | 910-842-3351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 428 HAMILTON DR SE
-----------------------------------------------------
City | BOLIVIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28422-7716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-964-3352
-----------------------------------------------------
Fax | 910-842-3351
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4124
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------