Provider Demographics
NPI:1235530635
Name:MILBURN, CLIVIA (BA, MED, MS, LCASA)
Entity Type:Individual
Prefix:
First Name:CLIVIA
Middle Name:
Last Name:MILBURN
Suffix:
Gender:F
Credentials:BA, MED, MS, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7828 MEADOWDALE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-4815
Mailing Address - Country:US
Mailing Address - Phone:704-564-1080
Mailing Address - Fax:704-537-6886
Practice Address - Street 1:5108 REAGAN DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-3103
Practice Address - Country:US
Practice Address - Phone:704-536-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor