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General NPI Number Information
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NPI Number | 1609599711
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Entity Type | Individual
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Provider Name | GEORGE ALBERT BACON JR. LCMHCS, LCAS
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Gender | Male
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Dates
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Enumeration Date | 09/22/2022
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Last Update Date | 09/23/2022
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Provider Practice Location Address
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Address Line | 2201 SEAGRAVE DR
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City | WINTERVILLE
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State | NC
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Zip | 28590-0119
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Country | US
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Telephone | 252-341-2761
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Fax |
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Provider Business Mailing Address
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Address Line | 2201 SEAGRAVE DR
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City | WINTERVILLE
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State | NC
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Zip | 28590-0119
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Country | US
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Telephone | 252-341-2761
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | S9005
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LCAS-2748
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License Number State | NC
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