Basic Information
Provider Information | |||||||||
NPI: | 1114100112 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLOUNT | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4300 SAPPHIRE CT STE 110 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278349079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2528307540 | ||||||||
FaxNumber: | 2524130932 | ||||||||
Practice Location | |||||||||
Address1: | 2245 STANTONSBURG RD | ||||||||
Address2: | STE. O | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278342868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527520483 | ||||||||
FaxNumber: | 2527573172 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2007 | ||||||||
LastUpdateDate: | 02/04/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6788 | NC | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 1365 | NC | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 6103793 | 05 | NC |   | MEDICAID | 416760 | 01 |   | MHN | OTHER |