Healthcare Provider Details

I. General information

NPI: 1437417243
Provider Name (Legal Business Name): LISA MICHELLE KORNEGAY LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 E GANNON AVE STE 103
ZEBULON NC
27597-9445
US

IV. Provider business mailing address

877 E GANNON AVE STE 103
ZEBULON NC
27597-9445
US

V. Phone/Fax

Practice location:
  • Phone: 314-496-2568
  • Fax: 919-832-0825
Mailing address:
  • Phone: 314-496-2568
  • Fax: 919-832-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1921
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: