MEDICARE: MS. CHARMETRI AVERIOUS WRICE-BULLUCK MSW P-LCSW

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	1041C0700X	Clinical Social Worker	P006741	NC

General Provider Information

NPI Number	:	1629358098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHARMETRI AVERIOUS WRICE-BULLUCK MSW P-LCSW

Provider Business Mailing Address
First Line	:	3512 LIONEL LN
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-2092
Country	:	US
Telephone Number	:	910-488-7682
Fax Number	:

Provider Business Practice Location Address
First Line	:	2905 BREEZEWOOD AVE
Second Line	:	SUITE 104
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5503
Country	:	US
Telephone Number	:	910-483-2183
Fax Number	:

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

Provider Enumeration Date	:	08/17/2011
Last Update Date	:	08/17/2011

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