Provider Demographics
NPI:1265746861
Name:ISOM, MARIE (EDD, LPC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:ISOM
Suffix:
Gender:F
Credentials:EDD, LPC
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:GOLDSBOROUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:500 WHALE AVE
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-5497
Mailing Address - Country:US
Mailing Address - Phone:843-685-2191
Mailing Address - Fax:
Practice Address - Street 1:1107 48TH AVE N STE 310A
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5443
Practice Address - Country:US
Practice Address - Phone:843-580-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5153101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional