Provider Demographics
NPI:1841407566
Name:MEDLIN, LARRY BERT
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:BERT
Last Name:MEDLIN
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:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional