=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407726870
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KETTIA FLORVILUS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2025
-----------------------------------------------------
Last Update Date | 11/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2151 US 401
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-689-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4009 BARRETT DR
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-6616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-689-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A22126
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------