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General NPI Number Information
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NPI Number | 1396254702
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Entity Type | Organization
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Legal Business Name | MILES 2 WISDOM LLC
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Dates
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Enumeration Date | 09/28/2017
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Last Update Date | 09/28/2017
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Provider Practice Location Address
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Address Line | 1012 PAMALEE DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-3833
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Country | US
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Telephone | 910-481-0560
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2472
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City | FAYETTEVILLE
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State | NC
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Zip | 28302-2472
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Country | US
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Telephone | 910-481-0560
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Fax |
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Authorized Official
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Title or Position | LPC
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Name | MRS. MARVA JOHNSON
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Credential | MA
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Telephone | 910-481-0560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4694
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License Number State | NE
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