Provider Demographics
NPI: | 1033259452 |
---|---|
Name: | LAIL, DONNA BOLICK (LCSW) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | DONNA |
Middle Name: | BOLICK |
Last Name: | LAIL |
Suffix: | |
Gender: | F |
Credentials: | LCSW |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 338 |
Mailing Address - Street 2: | 204 IDOL DRIVE |
Mailing Address - City: | THOMASVILLE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27361-0338 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 336-474-1238 |
Mailing Address - Fax: | 336-472-4605 |
Practice Address - Street 1: | 4475 UNION BAPTIST RD |
Practice Address - Street 2: | 1120 TAYLORSVILLE RD. |
Practice Address - City: | LENOIR |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28645-9284 |
Practice Address - Country: | US |
Practice Address - Phone: | 828-757-0700 |
Practice Address - Fax: | 828-757-0721 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-02-07 |
Last Update Date: | 2007-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | C002116 | 101YM0800X, 101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
Not Answered | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 6106083 | Medicaid |