MEDICARE: MR. DONALD MRDJENOVIC CCS

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	251	NC
2	251S00000X	Community/Behavioral Health Agency	MHL-016-034	NC
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	251	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598811002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD MRDJENOVIC CCS

Provider Business Mailing Address
First Line	:	113 ROCHELLE DR
Second Line	:	APT. N-4
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-2664
Country	:	US
Telephone Number	:	252-247-1109
Fax Number	:	252-247-1107

Provider Business Practice Location Address
First Line	:	3820 BRIDGES ST
Second Line	:	STE B
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-2979
Country	:	US
Telephone Number	:	252-648-3124
Fax Number	:

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

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	10/02/2018

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