MEDICARE: MCDERMOTT WILTON CONNOR MA, LCMHCA, LCASA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-25057	NC
2	101YM0800X	Mental Health Counselor
3	101YP2500X	Professional Counselor	A14619	NC

General Provider Information

NPI Number	:	1841756327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCDERMOTT WILTON CONNOR MA, LCMHCA, LCASA

Provider Business Mailing Address
First Line	:	PO BOX 1352
Second Line	:
City	:	SALISBURY
State	:	NC
Zip	:	28145-1352
Country	:	US
Telephone Number	:	980-330-8470
Fax Number	:

Provider Business Practice Location Address
First Line	:	4922 ALBEMARLE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6618
Country	:	US
Telephone Number	:	704-510-4285
Fax Number	:

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

Provider Enumeration Date	:	02/20/2019
Last Update Date	:	04/14/2022

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