Healthcare Provider Details

I. General information

NPI: 1396385936
Provider Name (Legal Business Name): MICHEALE COLLIE LCAS-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2020
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CRUTCHFIELD ST STE D
DURHAM NC
27704-2771
US

IV. Provider business mailing address

102 NEW STATESIDE DR
CHAPEL HILL NC
27516-1165
US

V. Phone/Fax

Practice location:
  • Phone: 919-251-8806
  • Fax:
Mailing address:
  • Phone: 919-942-2803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-26102
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA15467
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA15467
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: