Healthcare Provider Details

I. General information

NPI: 1699809301
Provider Name (Legal Business Name): AVALON COUNSELING CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 SE MAYNARD RD STE 204
CARY NC
27511-6945
US

IV. Provider business mailing address

1230 SE MAYNARD RD STE 204
CARY NC
27511-6945
US

V. Phone/Fax

Practice location:
  • Phone: 919-468-9122
  • Fax: 919-468-9122
Mailing address:
  • Phone: 919-468-9122
  • Fax: 919-468-9122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC003783
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierA8774
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDCOST PREFERRED
# 2
Identifier014WR
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBLUE CROSS
# 3
Identifier6005211
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 4
Identifier014WR
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerSTATE OF NC HEALTH PLAN

VIII. Authorized Official

Name: KELLY ORR BELK
Title or Position: MANAGER
Credential: LCSW
Phone: 919-468-9122