Healthcare Provider Details

I. General information

NPI: 1831682665
Provider Name (Legal Business Name): FAMILY TIES OF BRUNSWICK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N 3RD ST STE 401
WILMINGTON NC
28401-3474
US

IV. Provider business mailing address

720 N 3RD ST STE 401
WILMINGTON NC
28401-3474
US

V. Phone/Fax

Practice location:
  • Phone: 910-769-9126
  • Fax: 910-769-9169
Mailing address:
  • Phone: 910-769-9126
  • Fax: 910-769-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9796
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20956
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. BRIDGET DIXON MILLIKEN
Title or Position: OWNER
Credential: LCMHC, LCASA
Phone: 910-393-8502