Healthcare Provider Details

I. General information

NPI: 1124298997
Provider Name (Legal Business Name): MARLISA VAN HOUT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 S 17TH ST SUITE 1
WILMINGTON NC
28401-6679
US

IV. Provider business mailing address

1907 S 17TH ST SUITE 1
WILMINGTON NC
28401-6679
US

V. Phone/Fax

Practice location:
  • Phone: 910-343-8424
  • Fax: 910-343-6989
Mailing address:
  • Phone: 910-343-8424
  • Fax: 910-343-6989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MARLISA NANCE VAN HOUT
Title or Position: PRESIDENT
Credential: LPA
Phone: 910-343-8424