Provider Demographics
NPI:1659354660
Name:VANDUSER, MOLLY L (LPCS, NCC)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:L
Last Name:VANDUSER
Suffix:
Gender:F
Credentials:LPCS, NCC
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 2088
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-2088
Mailing Address - Country:US
Mailing Address - Phone:910-814-2197
Mailing Address - Fax:910-814-2167
Practice Address - Street 1:817 W FRONT ST
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-9735
Practice Address - Country:US
Practice Address - Phone:910-814-2197
Practice Address - Fax:910-814-2167
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4963101YP2500X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC142AYOtherBCBS
NC8849860OtherCIGNA
NC6102739Medicaid