Provider Demographics
NPI:1740266220
Name:ENGELSTATTER, MARY (PHD)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:
Last Name:ENGELSTATTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 COUNTRY CLUB ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-347-3010
Mailing Address - Fax:910-347-3201
Practice Address - Street 1:1703 COUNTRY CLUB ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-347-3010
Practice Address - Fax:910-347-3201
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2551103T00000X
NC4748103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC046UROtherBC/BS
NCQ49478AMedicare PIN