Provider Demographics
NPI:1326662867
Name:THOMPSON-BRYANT, TRACI LATRELLE
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LATRELLE
Last Name:THOMPSON-BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 184
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-1600
Mailing Address - Country:US
Mailing Address - Phone:843-789-4464
Mailing Address - Fax:
Practice Address - Street 1:120 SPRINGHALL DR STE D
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5335
Practice Address - Country:US
Practice Address - Phone:843-789-4464
Practice Address - Fax:843-970-2411
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093173874OtherGOLDEN CARE SOLUTIONS LLC