Provider Demographics
NPI:1639106511
Name:UPCHURCH, DONNA WILLSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:WILLSON
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 1/2 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2509
Mailing Address - Country:US
Mailing Address - Phone:803-252-1866
Mailing Address - Fax:803-252-1177
Practice Address - Street 1:1401 1/2 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2509
Practice Address - Country:US
Practice Address - Phone:803-252-1866
Practice Address - Fax:803-252-1177
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR16029364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCS689650281Medicare ID - Type Unspecified