Healthcare Provider Details

I. General information

NPI: 1114342904
Provider Name (Legal Business Name): TAMMY MCDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 WRIGHTSVILLE AVE STE 113
WILMINGTON NC
28403-3051
US

IV. Provider business mailing address

PO BOX 509
CASTLE HAYNE NC
28429-0509
US

V. Phone/Fax

Practice location:
  • Phone: 910-791-5757
  • Fax: 910-251-5893
Mailing address:
  • Phone: 910-791-5757
  • Fax: 910-251-5893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: