Provider Demographics
NPI:1174642482
Name:PEMBERTON-TODD, NATASHA DELICIA (LPC)
Entity Type:Individual
Prefix:MS
First Name:NATASHA
Middle Name:DELICIA
Last Name:PEMBERTON-TODD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:NATASHA
Other - Middle Name:DELICIA
Other - Last Name:PEMBERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:145 SCALEYBARK RD STE C
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2682
Mailing Address - Country:US
Mailing Address - Phone:704-567-8690
Mailing Address - Fax:
Practice Address - Street 1:145 SCALEYBARK RD STE C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2682
Practice Address - Country:US
Practice Address - Phone:704-567-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5225101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1513XOtherBLUE CROSS BLUE SHIELD
NC188286OtherMEDCOST
NC6103215Medicaid