Provider Demographics
NPI:1548074545
Name:ELMORE, BRENTLEY SUE
Entity type:Individual
Prefix:
First Name:BRENTLEY
Middle Name:SUE
Last Name:ELMORE
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 1:303 FREELAND WAY
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-8868
Mailing Address - Country:US
Mailing Address - Phone:757-372-1731
Mailing Address - Fax:
Practice Address - Street 1:303 FREELAND WAY
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-8868
Practice Address - Country:US
Practice Address - Phone:757-372-1731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCOU.10280101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional