MEDICARE: CARALEIGH BRADY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	5469	SC

General Provider Information

NPI Number	:	1740582873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARALEIGH BRADY LPC

Provider Business Mailing Address
First Line	:	1911 GADSDEN ST STE 204
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-6400
Country	:	US
Telephone Number	:	864-542-5756
Fax Number	:

Provider Business Practice Location Address
First Line	:	1911 GADSDEN ST STE 204
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-6400
Country	:	US
Telephone Number	:	864-542-5756
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2010
Last Update Date	:	11/26/2012

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