=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750520581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY SIMMONS KINDER MA; PLPC; PLCAS; ABD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2009
-----------------------------------------------------
Last Update Date | 02/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 BRAGG BLVD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-4889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-484-1500
-----------------------------------------------------
Fax | 910-223-1505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2469 CULBRETH RD
-----------------------------------------------------
City | EASTOVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28312-7578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-740-4736
-----------------------------------------------------
Fax | 910-223-1505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | PROVISIONAL
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | PROVISIONAL
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------