Basic Information
Provider Information | |||||||||
NPI: | 1295060507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STORY | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCAS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 617 S GREEN ST | ||||||||
Address2: | SUITE300 | ||||||||
City: | MORGANTON | ||||||||
State: | NC | ||||||||
PostalCode: | 286553517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284373000 | ||||||||
FaxNumber: | 8284374999 | ||||||||
Practice Location | |||||||||
Address1: | 350 E PARKER RD | ||||||||
Address2: |   | ||||||||
City: | MORGANTON | ||||||||
State: | NC | ||||||||
PostalCode: | 286555155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286240300 | ||||||||
FaxNumber: | 8285285800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2009 | ||||||||
LastUpdateDate: | 02/06/2017 | ||||||||
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 | 101YA0400X | 1211 | NC | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | LCAS 1211 | 01 | NC | LICENSE | OTHER |