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General NPI Number Information
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NPI Number | 1164812921
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Entity Type | Individual
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Provider Name | MIRIAM O'BANNON LCASA
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Gender | Female
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Dates
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Enumeration Date | 02/02/2015
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Last Update Date | 02/02/2015
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Provider Practice Location Address
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Address Line | 132 COMMERCIAL DR SUITE 120
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City | FOREST CITY
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State | NC
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Zip | 28043-2400
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Country | US
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Telephone | 828-248-1117
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Fax |
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Provider Business Mailing Address
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Address Line | 4685 HACKBERRY GROVE CIR APT 1827
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City | CHARLOTTE
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State | NC
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Zip | 28269-2431
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Country | US
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Telephone | 706-631-0570
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 2130A
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License Number State | NC
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