Provider Demographics
NPI:1568899821
Name:MASSEY, MARY H (LCAS-A)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:MASSEY
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 1:410 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-6478
Mailing Address - Country:US
Mailing Address - Phone:704-361-2612
Mailing Address - Fax:800-755-9281
Practice Address - Street 1:806 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-3800
Practice Address - Country:US
Practice Address - Phone:704-225-0584
Practice Address - Fax:800-755-9281
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3475-A101YA0400X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3475-AOtherNC SUBSTANCE ABUSE PRACTICE BOARD