Healthcare Provider Details

I. General information

NPI: 1649018565
Provider Name (Legal Business Name): EMILY CHARLOTTE GABRIELLE WAUN NCC, LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 VILLAGE DR
JACKSONVILLE NC
28546-7299
US

IV. Provider business mailing address

816 WELTON CIR
JACKSONVILLE NC
28546-7345
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-1400
  • Fax:
Mailing address:
  • Phone: 910-787-6711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA20061
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: