Healthcare Provider Details

I. General information

NPI: 1568391829
Provider Name (Legal Business Name): SERGIO MANCILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MORGANTON BLVD SW
LENOIR NC
28645-9691
US

IV. Provider business mailing address

2415 MORGANTON BLVD SW
LENOIR NC
28645-9691
US

V. Phone/Fax

Practice location:
  • Phone: 828-394-5563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA22192
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: