Provider Demographics
NPI:1043297443
Name:CAROL, VIVIAN (VIVIAN CAROL)
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:
Last Name:CAROL
Suffix:
Gender:F
Credentials:VIVIAN CAROL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 5TH ST
Mailing Address - Street 2:# 105
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2472
Mailing Address - Country:US
Mailing Address - Phone:704-366-3777
Mailing Address - Fax:
Practice Address - Street 1:1801 E 5TH ST
Practice Address - Street 2:# 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2472
Practice Address - Country:US
Practice Address - Phone:704-366-3777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3340101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC212420Medicare UPIN
NC1207VMedicare UPIN