MEDICARE: ROBERT MARK STURDIVANT LPC

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	101YP2500X	Professional Counselor	6838	NC

General Provider Information

NPI Number	:	1962669689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT MARK STURDIVANT LPC

Provider Business Mailing Address
First Line	:	895 STATE FARM RD
Second Line	:	SUITE 508
City	:	BOONE
State	:	NC
Zip	:	28607-4917
Country	:	US
Telephone Number	:	828-263-5666
Fax Number	:	828-262-5687

Provider Business Practice Location Address
First Line	:	1650 HWY 18 SOUTH
Second Line	:
City	:	SPARTA
State	:	NC
Zip	:	28675-8478
Country	:	US
Telephone Number	:	336-372-4095
Fax Number	:	828-262-5687

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

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	05/20/2008

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