Provider Demographics
NPI:1497223119
Name:ELEAZER, MARY ALICE (LCAS-A)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:ELEAZER
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 SHEPHERD WATCH CT APT A
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-3566
Mailing Address - Country:US
Mailing Address - Phone:336-451-8101
Mailing Address - Fax:
Practice Address - Street 1:1 CENTERVIEW DR STE 300
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3712
Practice Address - Country:US
Practice Address - Phone:336-617-0469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20629101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)