Provider Demographics
NPI:1417961491
Name:TENBRUNSEL, LAURA H (MCD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:H
Last Name:TENBRUNSEL
Suffix:
Gender:F
Credentials:MCD
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 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 N HOSPITAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4800
Practice Address - Country:US
Practice Address - Phone:803-936-7530
Practice Address - Fax:803-936-7532
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC231H00000X
SC3434231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4644OtherMEDICAID GROUP NUMBER
SCQ349201305OtherMEDICARE PTAN
SCSA0762Medicaid