Healthcare Provider Details

I. General information

NPI: 1093475360
Provider Name (Legal Business Name): LYDIAELISEE PHILOGENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8505 KENBROOKE DR APT 1402
CHARLOTTE NC
28262-5633
US

IV. Provider business mailing address

7319 MATTHEWS MINT HILL RD
MINT HILL NC
28227-7594
US

V. Phone/Fax

Practice location:
  • Phone: 304-894-5987
  • Fax:
Mailing address:
  • Phone: 304-894-5987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23216
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: