Healthcare Provider Details

I. General information

NPI: 1902055528
Provider Name (Legal Business Name): ELIZABETH FAYE FLACK LCAS, LPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 TRADD CT
WILMINGTON NC
28401-6637
US

IV. Provider business mailing address

1920 TRADD CT
WILMINGTON NC
28401-6637
US

V. Phone/Fax

Practice location:
  • Phone: 910-343-6890
  • Fax: 910-332-1233
Mailing address:
  • Phone: 910-343-6890
  • Fax: 910-332-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3599
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberLCAS-1932
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: