Provider Demographics
NPI:1013273572
Name:BRUNSON-SAMUEL, MYRA (MSW, LISW-CP)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:BRUNSON-SAMUEL
Suffix:
Gender:F
Credentials:MSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 PELHAM RD STE 252
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5044
Mailing Address - Country:US
Mailing Address - Phone:864-381-7818
Mailing Address - Fax:855-415-9033
Practice Address - Street 1:3620 PELHAM RD STE 252
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5044
Practice Address - Country:US
Practice Address - Phone:864-381-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC118301041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical