MEDICARE: FAMILY TIES OF BRUNSWICK, LLC

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
2	101YM0800X	Mental Health Counselor	9796	NC
3	101YM0800X	Mental Health Counselor
4	101YP2500X	Professional Counselor	20956	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831682665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY TIES OF BRUNSWICK, LLC

Provider Business Mailing Address
First Line	:	720 N 3RD ST STE 401
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-3474
Country	:	US
Telephone Number	:	910-769-9126
Fax Number	:	910-769-9169

Provider Business Practice Location Address
First Line	:	720 N 3RD ST STE 401
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-3474
Country	:	US
Telephone Number	:	910-769-9126
Fax Number	:	910-769-9169

Authorized Official
Title or Position	:	OWNER
Name	:	MS. BRIDGET DIXON MILLIKEN
Credential	:	LCMHC, LCASA
Telephone Number	:	910-393-8502

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	11/16/2023

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Directions to “FAMILY TIES OF BRUNSWICK, LLC ” Practice Location

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