=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144847377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMICA MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2020
-----------------------------------------------------
Last Update Date | 07/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CENTRAL AVE
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28801-2419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-215-9888
-----------------------------------------------------
Fax | 855-962-2344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 STARS FOREVER DR
-----------------------------------------------------
City | BLACK MOUNTAIN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28711-8845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-215-9888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIA MACDOUGALL
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 828-215-9888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------