Healthcare Provider Details

I. General information

NPI: 1245616259
Provider Name (Legal Business Name): MIRANDA SLATER LCMHC, LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 OLEANDER DR STE 204
WILMINGTON NC
28403-6808
US

IV. Provider business mailing address

205 ADELE CT
WILMINGTON NC
28412-3166
US

V. Phone/Fax

Practice location:
  • Phone: 910-367-5089
  • Fax: 910-756-4424
Mailing address:
  • Phone: 910-616-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA10746
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-20590
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: