Provider Demographics
NPI:1558423608
Name:WILLINGHAM, MARY A (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 BONNER DR
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-8948
Mailing Address - Country:US
Mailing Address - Phone:336-889-6105
Mailing Address - Fax:336-384-9167
Practice Address - Street 1:315 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2911
Practice Address - Country:US
Practice Address - Phone:336-387-6161
Practice Address - Fax:336-387-9167
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2119101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103455Medicaid