Healthcare Provider Details

I. General information

NPI: 1255831707
Provider Name (Legal Business Name): ELON PSYCHOLOGICAL & WELLNESS SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 UNIVERSITY DR SUITE 105 #1016
BURLINGTON NC
27215
US

IV. Provider business mailing address

1183 UNIVERSITY DR SUITE 105 #1016
BURLINGTON NC
27215
US

V. Phone/Fax

Practice location:
  • Phone: 336-202-6634
  • Fax:
Mailing address:
  • Phone: 743-218-0720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4989
License Number StateNC

VIII. Authorized Official

Name: DR. MARIE SHAW
Title or Position: PSYCHOLOGIST
Credential:
Phone: 743-218-0720