Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 101YA0400X | Counselor | Addiction (Substance Use Disorder) | LCAS-1691 | NORTH CAROLINA | No |
| 2 | 101YM0800X | Counselor | Mental Health | S10914 | NORTH CAROLINA | Yes |
| 3 | 101YA0400X | Counselor | Addiction (Substance Use Disorder) | CCS-467 | NORTH CAROLINA | No |
| 4 | 101YM0800X | Counselor | Mental Health | 10914 | NORTH CAROLINA | No |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 10914 | OTHER | NORTH CAROLINA | LICENSED PROFESSIONAL COUNSELOR |
| 2 | 1932231891 | MEDICAID | NORTH CAROLINA | |
| 3 | 1518 | OTHER | GEORGIA | CACII CERT ADD COUNS II |
| 4 | LPC004663 | OTHER | GEORGIA | LICENSED PROFESSIONAL COUNSELOR |
| 5 | 1691 | OTHER | NORTH CAROLINA | LICENSED CLINICIAL ADDICTION SPECIALIST |
| 6 | C-33801 | OTHER | GEORGIA | CERT CLINICAL EVALUATOR |
| 7 | 467 | OTHER | NORTH CAROLINA | CERTIFIED CLINICAL SUPERVISOR |
| 8 | 0690 | OTHER | GEORGIA | CERT RISK RED PROG INSTRU |
| 9 | 11841 | OTHER | GEORGIA | SAP SUBSTANCE ABUSE PROF |
| 10 | T-34401 | OTHER | GEORGIA | ASAM LEVEL I TX PROVIDER |
