Provider Demographics
NPI:1710126412
Name:SELF-FULL PSYCHOTHERAPY, PC
Entity Type:Organization
Organization Name:SELF-FULL PSYCHOTHERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:CHRISTIN
Authorized Official - Last Name:LUKE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:704-576-3635
Mailing Address - Street 1:106 OAKLEY AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-8620
Mailing Address - Country:US
Mailing Address - Phone:704-576-3635
Mailing Address - Fax:704-889-5649
Practice Address - Street 1:106 OAKLEY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-8620
Practice Address - Country:US
Practice Address - Phone:704-576-3635
Practice Address - Fax:704-889-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC004450251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002779Medicaid