Provider Demographics
NPI:1255715801
Name:AYALA, JUDITH LISETH (LPC, LCAS)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LISETH
Last Name:AYALA
Suffix:
Gender:F
Credentials:LPC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1552 UNION RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5523
Mailing Address - Country:US
Mailing Address - Phone:704-833-0154
Mailing Address - Fax:704-833-7076
Practice Address - Street 1:1562 UNION RD STE B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2210
Practice Address - Country:US
Practice Address - Phone:704-201-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20973101YA0400X
NCA11438101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)