Healthcare Provider Details

I. General information

NPI: 1922768258
Provider Name (Legal Business Name): MY GUIDING LIGHT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 DUNBROOK DR
WINTERVILLE NC
28590-5812
US

IV. Provider business mailing address

3141 N CONTENTNEA ST
FARMVILLE NC
27828-1477
US

V. Phone/Fax

Practice location:
  • Phone: 252-227-9373
  • Fax:
Mailing address:
  • Phone: 252-320-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSE MARIE LAWRENCE
Title or Position: THERAPIST/OWNER
Credential: LCMHC
Phone: 252-227-9373