Healthcare Provider Details

I. General information

NPI: 1548104458
Provider Name (Legal Business Name): AILEEN PATRICE CARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 W 25TH ST
WINSTON SALEM NC
27105-5014
US

IV. Provider business mailing address

421 W 25TH ST
WINSTON SALEM NC
27105-5014
US

V. Phone/Fax

Practice location:
  • Phone: 336-705-5304
  • Fax: 336-705-5304
Mailing address:
  • Phone: 336-705-5304
  • Fax: 336-705-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA22720
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: