Healthcare Provider Details

I. General information

NPI: 1043299068
Provider Name (Legal Business Name): MARY DOUGLAS UNGETHEIM MA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 BETHESDA PL OPTIONS OF WINSTON SALEM SUITE 103
WINSTON SALEM NC
27103-3331
US

IV. Provider business mailing address

3000 BETHESDA PL OPTIONS OF WINSTON SALEM SUITE 103
WINSTON SALEM NC
27103-3331
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-9768
  • Fax: 336-768-9557
Mailing address:
  • Phone: 336-768-9768
  • Fax: 336-768-9557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number527
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: