Provider Demographics
NPI:1083155154
Name:WOOTEN, THEA (MA, LCASA)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20014 NORTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6433
Mailing Address - Country:US
Mailing Address - Phone:704-872-0234
Mailing Address - Fax:704-818-1114
Practice Address - Street 1:612 SIGNAL HILL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4353
Practice Address - Country:US
Practice Address - Phone:704-872-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23390101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)