Healthcare Provider Details

I. General information

NPI: 1568711109
Provider Name (Legal Business Name): MARY DIANNE BRANCH LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104B S MAIN ST
LEXINGTON NC
27292-3134
US

IV. Provider business mailing address

1104B S MAIN ST
LEXINGTON NC
27292-3134
US

V. Phone/Fax

Practice location:
  • Phone: 336-300-8826
  • Fax:
Mailing address:
  • Phone: 336-300-8826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-2935
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: