Healthcare Provider Details

I. General information

NPI: 1891865218
Provider Name (Legal Business Name): CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 BURNT MILL DR STE 1
WILMINGTON NC
28403-2570
US

IV. Provider business mailing address

3240 BURNT MILL DR STE 101
WILMINGTON NC
28403-2576
US

V. Phone/Fax

Practice location:
  • Phone: 910-790-9500
  • Fax: 910-796-8111
Mailing address:
  • Phone: 910-790-9500
  • Fax: 910-796-8111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2805
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLPC6828
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC006434
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003399
License Number StateNC

VIII. Authorized Official

Name: MACON FUNDERBURK
Title or Position: OFFICE MANAGER
Credential:
Phone: 910-790-9500