Provider Demographics
NPI:1710072699
Name:VANHOUT, MARLISA (LPA)
Entity Type:Individual
Prefix:
First Name:MARLISA
Middle Name:
Last Name:VANHOUT
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:MARLISA
Other - Middle Name:
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPA
Mailing Address - Street 1:1907 S 17TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6626
Mailing Address - Country:US
Mailing Address - Phone:910-343-8424
Mailing Address - Fax:910-343-6989
Practice Address - Street 1:1907 S 17TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6626
Practice Address - Country:US
Practice Address - Phone:910-343-8424
Practice Address - Fax:910-343-6989
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107225Medicaid