Provider Demographics
NPI: | 1437644291 |
---|---|
Name: | NEVILLE, MARY CAROLINE (LCMHCA, LCASA) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARY |
Middle Name: | CAROLINE |
Last Name: | NEVILLE |
Suffix: | |
Gender: | F |
Credentials: | LCMHCA, LCASA |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 615 SHIPYARD BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | WILMINGTON |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28412-6431 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-343-0145 |
Mailing Address - Fax: | 910-202-9966 |
Practice Address - Street 1: | 615 SHIPYARD BLVD |
Practice Address - Street 2: | |
Practice Address - City: | WILMINGTON |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28412 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-343-0145 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2018-06-25 |
Last Update Date: | 2021-04-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 24652 | 101YA0400X |
NC | A14068 | 101YM0800X |
101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |