Healthcare Provider Details

I. General information

NPI: 1356517536
Provider Name (Legal Business Name): PSYCLINC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 S ASPEN ST
LINCOLNTON NC
28092-2735
US

IV. Provider business mailing address

518 S ASPEN ST
LINCOLNTON NC
28092-2735
US

V. Phone/Fax

Practice location:
  • Phone: 704-530-0850
  • Fax: 704-735-9810
Mailing address:
  • Phone: 704-530-0850
  • Fax: 704-735-9810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3163
License Number StateNC

VIII. Authorized Official

Name: DR. MARY REAVIS
Title or Position: OWNER OF BUSINESS
Credential: PH.D.
Phone: 704-530-0850