Provider Demographics
NPI:1235677782
Name:MICOL, PAULA WILSON (LMBT)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:WILSON
Last Name:MICOL
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 3RD AVENUE DR NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-4854
Mailing Address - Country:US
Mailing Address - Phone:828-855-1711
Mailing Address - Fax:
Practice Address - Street 1:1083 3RD AVENUE DR NW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-4854
Practice Address - Country:US
Practice Address - Phone:828-855-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLMBT #15614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist