=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336963412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVELYN ALEXANDRA BOSTANY LMFTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5950 FAIRVIEW RD STE 700
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-0085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-255-5335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5950 FAIRVIEW RD STE 700
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-0085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-255-5335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 10606A
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 10606A
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------