Provider Demographics
NPI:1295791143
Name:STORY, MARY SANDRA (PSYD, PC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:SANDRA
Last Name:STORY
Suffix:
Gender:F
Credentials:PSYD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8512 SIX FORKS RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-2962
Mailing Address - Country:US
Mailing Address - Phone:919-844-8711
Mailing Address - Fax:919-844-8706
Practice Address - Street 1:8512 SIX FORKS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2962
Practice Address - Country:US
Practice Address - Phone:919-844-8711
Practice Address - Fax:919-844-8706
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2659103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000365Medicaid
NC2819893BMedicare ID - Type UnspecifiedPROVIDER NUMBER