MEDICARE: MAYA SIMONE WHITE BALLOU LCAS-A

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-30724	NC

General Provider Information

NPI Number	:	1699633271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYA SIMONE WHITE BALLOU LCAS-A

Provider Business Mailing Address
First Line	:	6636 E W T HARRIS BLVD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-5133
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6636 E W T HARRIS BLVD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-5133
Country	:	US
Telephone Number	:	704-553-5392
Fax Number	:

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

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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