Provider Demographics
NPI:1497247696
Name:AUGUSTONO, DONNA (MA, LCAS-A)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:AUGUSTONO
Suffix:
Gender:F
Credentials:MA, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SAINT JOHNS ST
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7997
Mailing Address - Country:US
Mailing Address - Phone:919-880-2828
Mailing Address - Fax:
Practice Address - Street 1:2321 CRABTREE BLVD STE 250
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-2263
Practice Address - Country:US
Practice Address - Phone:919-848-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20376101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101-YA0400XMedicaid