Provider Demographics
NPI:1639932130
Name:FOSTER, MICAH JOE
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:JOE
Last Name:FOSTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:LOCUST
Mailing Address - State:NC
Mailing Address - Zip Code:28097-0487
Mailing Address - Country:US
Mailing Address - Phone:704-888-1616
Mailing Address - Fax:704-888-1670
Practice Address - Street 1:4310 THERMAL AVE STE C
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:NC
Practice Address - Zip Code:28107-9393
Practice Address - Country:US
Practice Address - Phone:704-888-1616
Practice Address - Fax:704-888-1670
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19664101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health