=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467088401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FERNANDUS VINSON LCMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2020
-----------------------------------------------------
Last Update Date | 08/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 CUMBERLAND ST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-797-9335
-----------------------------------------------------
Fax | 910-485-1543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 CUMBERLAND ST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-797-9335
-----------------------------------------------------
Fax | 910-485-1543
-----------------------------------------------------
=====================================================
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 | 15490
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------