Healthcare Provider Details

I. General information

NPI: 1205791464
Provider Name (Legal Business Name): MANDY L DIFELICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 MILITARY CUTOFF RD STE 210
WILMINGTON NC
28403-3638
US

IV. Provider business mailing address

1437 MILITARY CUTOFF RD STE 210
WILMINGTON NC
28403-3638
US

V. Phone/Fax

Practice location:
  • Phone: 910-240-2489
  • Fax:
Mailing address:
  • Phone: 910-240-2489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-30856
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP022260
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: