=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255572525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CSCLDL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2009
-----------------------------------------------------
Last Update Date | 03/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2014 HOPE MILLS RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-425-6136
-----------------------------------------------------
Fax | 910-424-0198
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4323 DOMINIQUE ST
-----------------------------------------------------
City | HOPE MILLS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28348-2854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-322-1479
-----------------------------------------------------
Fax | 910-339-2481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. CORINNA SUZETTE MCMILLON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 910-322-1479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6710
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------