MEDICARE: MS. VIVIAN CAROL VIVIAN CAROL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3340	NC

General Provider Information

NPI Number	:	1043297443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIVIAN CAROL VIVIAN CAROL

Provider Business Mailing Address
First Line	:	1801 E 5TH ST
Second Line	:	# 105
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2472
Country	:	US
Telephone Number	:	704-366-3777
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 E 5TH ST
Second Line	:	# 105
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2472
Country	:	US
Telephone Number	:	704-366-3777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	07/09/2007

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