MEDICARE: JANICE LAKESHA MCGILBERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	8708	NC
2	103T00000X	Psychologist	5024	NC

General Provider Information

NPI Number	:	1104110162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANICE LAKESHA MCGILBERRY

Provider Business Mailing Address
First Line	:	4 MULBERRY CT
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-4521
Country	:	US
Telephone Number	:	919-908-9308
Fax Number	:	919-287-2206

Provider Business Practice Location Address
First Line	:	1802 MARTIN LUTHER KING PKWY STE 107
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-3586
Country	:	US
Telephone Number	:	919-908-9308
Fax Number	:	919-287-2206

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2011
Last Update Date	:	04/03/2020

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