Provider Demographics
NPI:1356984223
Name:GURUNG, MAMATA (MA, LPCA)
Entity type:Individual
Prefix:MISS
First Name:MAMATA
Middle Name:
Last Name:GURUNG
Suffix:
Gender:F
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 JESTER LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4327
Mailing Address - Country:US
Mailing Address - Phone:704-733-0791
Mailing Address - Fax:
Practice Address - Street 1:5108 REAGAN DR STE 14
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-1395
Practice Address - Country:US
Practice Address - Phone:704-332-8787
Practice Address - Fax:704-332-8788
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15205101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional