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General NPI Number Information
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NPI Number | 1891865218
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Entity Type | Organization
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Legal Business Name | CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 08/21/2024
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Provider Practice Location Address
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Address Line | 3240 BURNT MILL DR STE 1
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City | WILMINGTON
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State | NC
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Zip | 28403-2570
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Country | US
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Telephone | 910-790-9500
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Fax | 910-796-8111
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Provider Business Mailing Address
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Address Line | 3240 BURNT MILL DR STE 101
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City | WILMINGTON
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State | NC
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Zip | 28403-2576
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Country | US
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Telephone | 910-790-9500
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Fax | 910-796-8111
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MACON FUNDERBURK
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Credential |
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Telephone | 910-790-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | LPC6828
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C006434
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | L003399
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License Number State | NC
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2805
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License Number State | NC
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