=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386467462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BREAUNNA HEARD LCSW-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5040 NEW CENTRE DR STE D
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-604-2302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 CHURCH ST
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-2163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-705-3129
-----------------------------------------------------
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 | P021486
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------