Provider Demographics
NPI:1104324359
Name:BRANSCOMB, RODERICK (MA)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:BRANSCOMB
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 BELL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2554
Mailing Address - Country:US
Mailing Address - Phone:762-207-2641
Mailing Address - Fax:
Practice Address - Street 1:2330 BELL ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2554
Practice Address - Country:US
Practice Address - Phone:762-207-2641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA82-1429066Medicaid
82-1429066OtherCOUNSELING