MEDICARE: DARA COBB LEWIS MDIV

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
2	101YP1600X	Pastoral Counselor

General Provider Information

NPI Number	:	1679990436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARA COBB LEWIS MDIV

Provider Business Mailing Address
First Line	:	4114 HATHAWAY HILLS DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-7671
Country	:	US
Telephone Number	:	704-615-6622
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 OAK GROVE ST UNIT 4
Second Line	:
City	:	MOUNT HOLLY
State	:	NC
Zip	:	28120-1655
Country	:	US
Telephone Number	:	704-612-6774
Fax Number	:

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

Provider Enumeration Date	:	03/18/2014
Last Update Date	:	12/07/2021

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