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General NPI Number Information
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NPI Number | 1710126412
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Entity Type | Organization
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Legal Business Name | SELF-FULL PSYCHOTHERAPY, PC
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Dates
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Enumeration Date | 02/19/2009
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Last Update Date | 02/19/2009
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Provider Practice Location Address
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Address Line | 106 OAKLEY AVE SUITE 300
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City | PINEVILLE
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State | NC
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Zip | 28134-8620
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Country | US
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Telephone | 704-576-3635
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Fax | 704-889-5649
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Provider Business Mailing Address
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Address Line | 106 OAKLEY AVE SUITE 300
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City | PINEVILLE
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State | NC
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Zip | 28134-8620
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Country | US
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Telephone | 704-576-3635
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Fax | 704-889-5649
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MS. DOROTHY CHRISTIN LUKE
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Credential | MSW, LCSW
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Telephone | 704-576-3635
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | C004450
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License Number State | NC
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