Provider Demographics
NPI:1972074409
Name:MCPHAUL, VONTAVIA
Entity Type:Individual
Prefix:
First Name:VONTAVIA
Middle Name:
Last Name:MCPHAUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLYDE ST
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-3117
Mailing Address - Country:US
Mailing Address - Phone:910-250-8811
Mailing Address - Fax:910-401-1053
Practice Address - Street 1:111 CLYDE ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-3117
Practice Address - Country:US
Practice Address - Phone:910-250-8811
Practice Address - Fax:910-401-1053
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional