Provider Demographics
NPI:1356819130
Name:MESIMER, BRIAN ALTON
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALTON
Last Name:MESIMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 LADY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3402
Mailing Address - Country:US
Mailing Address - Phone:803-779-1995
Mailing Address - Fax:
Practice Address - Street 1:1500 LADY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3402
Practice Address - Country:US
Practice Address - Phone:803-779-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6444101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor