Healthcare Provider Details

I. General information

NPI: 1912766411
Provider Name (Legal Business Name): ELIZABETH TICE LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8705 GROUSE RUN LN
FAYETTEVILLE NC
28314-6076
US

IV. Provider business mailing address

8705 GROUSE RUN LN
FAYETTEVILLE NC
28314-6076
US

V. Phone/Fax

Practice location:
  • Phone: 910-745-7527
  • Fax:
Mailing address:
  • Phone: 360-980-1057
  • Fax: 919-205-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA19566
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: