Provider Demographics
NPI:1467820803
Name:BROGDON, WILLIBA
Entity Type:Individual
Prefix:
First Name:WILLIBA
Middle Name:
Last Name:BROGDON
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 1:730 BROAD ST
Mailing Address - Street 2:C
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-3356
Mailing Address - Country:US
Mailing Address - Phone:704-701-0836
Mailing Address - Fax:
Practice Address - Street 1:730 BROAD ST
Practice Address - Street 2:C
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-3356
Practice Address - Country:US
Practice Address - Phone:704-701-0836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC000-000-0000OtherTARGETED CASE MANAGEMENT SERVICES