MEDICARE: LESLIE MULLIGAN LPC, LCPC

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	101YM0800X	Mental Health Counselor	CC3059	ME
2	101YP2500X	Professional Counselor	13266	NC
3	101YP2500X	Professional Counselor	CC3059	ME
4	101YM0800X	Mental Health Counselor	13266	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26-2062123	OTHER	ME	FEIN

General Provider Information

NPI Number	:	1184779993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE MULLIGAN LPC, LCPC

Provider Business Mailing Address
First Line	:	3515 W MARKET ST STE 120
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27403-4441
Country	:	US
Telephone Number	:	336-323-2660
Fax Number	:

Provider Business Practice Location Address
First Line	:	3515 W MARKET ST STE 120
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27403-4441
Country	:	US
Telephone Number	:	336-323-2660
Fax Number	:

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

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	03/29/2019

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