Basic Information
Provider Information | |||||||||
NPI: | 1225149958 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIS | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JARMAN | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4300 SAPPHIRE CT STE 110 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278349079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2528307561 | ||||||||
FaxNumber: | 2524130932 | ||||||||
Practice Location | |||||||||
Address1: | 2901 N HERRITAGE ST | ||||||||
Address2: |   | ||||||||
City: | KINSTON | ||||||||
State: | NC | ||||||||
PostalCode: | 285011581 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2522332383 | ||||||||
FaxNumber: | 2525233148 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 07/20/2015 | ||||||||
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 | 1041C0700X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C005322 | NC | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 6106492 | 05 | NC |   | MEDICAID | Q37795A | 01 | NC | MEDICARE | OTHER |