Provider Demographics
NPI:1164812921
Name:O'BANNON, MIRIAM (LCASA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:O'BANNON
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 HACKBERRY GROVE CIR
Mailing Address - Street 2:APT 1827
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-2431
Mailing Address - Country:US
Mailing Address - Phone:706-631-0570
Mailing Address - Fax:
Practice Address - Street 1:132 COMMERCIAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-2400
Practice Address - Country:US
Practice Address - Phone:828-248-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2130A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)