=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366072027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLYSON KATE AYCOCK LCSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2020
-----------------------------------------------------
Last Update Date | 01/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2577 W 5TH ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27834-7813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-707-5013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2322 PAULS PATH RD
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28504-9033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-361-3123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P013903
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------