Provider Demographics
NPI:1053822130
Name:AGE, GENEVI J (LCAS-A)
Entity Type:Individual
Prefix:MS
First Name:GENEVI
Middle Name:J
Last Name:AGE
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5233 SUNDANCE WAY UNIT 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-5771
Mailing Address - Country:US
Mailing Address - Phone:910-619-4964
Mailing Address - Fax:
Practice Address - Street 1:5233 SUNDANCE WAY UNIT 101
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-5771
Practice Address - Country:US
Practice Address - Phone:910-649-4964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23005103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)