Provider Demographics
NPI:1972934123
Name:BRASWELL, ANDORA
Entity Type:Individual
Prefix:
First Name:ANDORA
Middle Name:
Last Name:BRASWELL
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 1:719 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-2517
Mailing Address - Country:US
Mailing Address - Phone:843-423-1811
Mailing Address - Fax:
Practice Address - Street 1:719 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-2517
Practice Address - Country:US
Practice Address - Phone:843-423-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
SC8841104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker