Provider Demographics
NPI:1730236951
Name:BRANSCOMB, LOUISA PORTER (PHD)
Entity type:Individual
Prefix:DR
First Name:LOUISA
Middle Name:PORTER
Last Name:BRANSCOMB
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BOWEN RD NE
Mailing Address - Street 2:
Mailing Address - City:WHITE
Mailing Address - State:GA
Mailing Address - Zip Code:30184-2026
Mailing Address - Country:US
Mailing Address - Phone:678-721-0103
Mailing Address - Fax:770-382-0023
Practice Address - Street 1:5 S PUBLIC SQ
Practice Address - Street 2:SUITE 103
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3348
Practice Address - Country:US
Practice Address - Phone:678-721-0103
Practice Address - Fax:770-382-0023
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001315103TC0700X
WAPY00002224103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11410766OtherCAQH
GA11410766OtherCAQH
P93609Medicare UPIN