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General NPI Number Information
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NPI Number | 1255831707
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Entity Type | Organization
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Legal Business Name | ELON PSYCHOLOGICAL & WELLNESS SERVICES, PLLC
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Dates
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Enumeration Date | 02/20/2018
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Last Update Date | 02/11/2022
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Provider Practice Location Address
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Address Line | 1183 UNIVERSITY DR SUITE 105 #1016
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City | BURLINGTON
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State | NC
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Zip | 27215
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Country | US
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Telephone | 336-202-6634
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Fax |
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Provider Business Mailing Address
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Address Line | 1183 UNIVERSITY DR SUITE 105 #1016
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City | BURLINGTON
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State | NC
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Zip | 27215
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Country | US
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Telephone | 743-218-0720
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. MARIE SHAW
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Credential |
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Telephone | 743-218-0720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 4989
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License Number State | NC
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