=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174678155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACI CHEVONN BLUE LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 12/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 W MORGAN ST APT 410
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27601-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-835-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 W MORGAN ST APT 410
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27601-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-835-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 4643
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------