Healthcare Provider Details

I. General information

NPI: 1790609956
Provider Name (Legal Business Name): IRELAND OTTERLEE LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N BROAD ST
BREVARD NC
28712-3303
US

IV. Provider business mailing address

31 N BROAD ST STE A
BREVARD NC
28712-3981
US

V. Phone/Fax

Practice location:
  • Phone: 704-375-5354
  • Fax: 704-375-3069
Mailing address:
  • Phone: 512-547-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: