{
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"NamePrefix": null,
"NameSuffix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2313 -B EXECUTIVE PARK",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GREENVILLE",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "27834",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "252-439-2275",
"MailingAddressFaxNumber": "252-439-2353",
"FirstLinePracticeLocationAddress": "2313 EXECUTIVE CIR",
"SecondLinePracticeLocationAddress": "SUITE B",
"PracticeLocationAddressCityName": "GREENVILLE",
"PracticeLocationAddressStateName": "NC",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "252-439-2275",
"PracticeLocationAddressFaxNumber": "252-439-2353",
"EnumerationDate": "01/02/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "JONES",
"AuthorizedOfficialFirstName": "GERALDINE",
"AuthorizedOfficialMiddleName": "MONK",
"AuthorizedOfficialTitle": "DIRECTOR",
"AuthorizedOfficialNamePrefix": "MS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "SOCIAL WORKER",
"AuthorizedOfficialTelephoneNumber": "252-439-2275",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": "89130GY",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}