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General NPI Number Information
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NPI Number | 1356517536
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Entity Type | Organization
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Legal Business Name | PSYCLINC
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Dates
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Enumeration Date | 05/07/2008
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Last Update Date | 01/22/2013
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Provider Practice Location Address
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Address Line | 518 S ASPEN ST
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City | LINCOLNTON
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State | NC
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Zip | 28092-2735
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Country | US
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Telephone | 704-530-0850
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Fax | 704-735-9810
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Provider Business Mailing Address
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Address Line | 518 S ASPEN ST
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City | LINCOLNTON
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State | NC
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Zip | 28092-2735
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Country | US
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Telephone | 704-530-0850
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Fax | 704-735-9810
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Authorized Official
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Title or Position | OWNER OF BUSINESS
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Name | DR. MARY REAVIS
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Credential | PH.D.
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Telephone | 704-530-0850
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3163
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License Number State | NC
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