Provider Demographics
NPI:1265433411
Name:FISHER, BRENDA SHARALYN (MA, LCAS LPC LPC-S)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:SHARALYN
Last Name:FISHER
Suffix:
Gender:F
Credentials:MA, LCAS LPC LPC-S
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:SHARALYN
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC LCAS LPC-S
Mailing Address - Street 1:428 HAMILTON DR SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-7716
Mailing Address - Country:US
Mailing Address - Phone:910-964-3352
Mailing Address - Fax:910-842-3351
Practice Address - Street 1:4320 SOUTHPORT SUPPLY RD SE
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-8158
Practice Address - Country:US
Practice Address - Phone:910-964-3352
Practice Address - Fax:910-842-3351
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340955OtherMHN
NC340955OtherBC/BS
NC6102619Medicaid