Provider Demographics
NPI:1447798640
Name:EAGLE EYE COUNSELING & CONSULTING, PLLC
Entity Type:Organization
Organization Name:EAGLE EYE COUNSELING & CONSULTING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S, LCAS, CCS
Authorized Official - Phone:704-750-1007
Mailing Address - Street 1:1775 APPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-9100
Mailing Address - Country:US
Mailing Address - Phone:704-421-4746
Mailing Address - Fax:
Practice Address - Street 1:1118 SAM NEWELL RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5041
Practice Address - Country:US
Practice Address - Phone:704-750-1007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7638101Y00000X
NC1717101YA0400X
NCS7638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1366755282Medicaid