MEDICARE: MS. TERESA C MAYLE MSRC, LPCA

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	A11353	NC
2	101YM0800X	Mental Health Counselor	A11353	NC
3	101YP2500X	Professional Counselor	A11353	NC

General Provider Information

NPI Number	:	1295282309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERESA C MAYLE MSRC, LPCA

Provider Business Mailing Address
First Line	:	608 JACKSON ST
Second Line	:	SUITE F
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-2600
Country	:	US
Telephone Number	:	252-308-0744
Fax Number	:	252-308-0092

Provider Business Practice Location Address
First Line	:	608 JACKSON ST
Second Line	:	SUITE F
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-2600
Country	:	US
Telephone Number	:	252-308-0744
Fax Number	:	252-308-0092

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

Provider Enumeration Date	:	09/07/2016
Last Update Date	:	09/07/2016

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