Basic Information
| Provider Information | |||||||||
| NPI: | 1396283669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | DESTINY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 N MARION DR | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275347613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195817720 | ||||||||
| FaxNumber: | 9195870007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 WAYNE MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275342203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195870001 | ||||||||
| FaxNumber: | 9195870007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2017 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | A122778 | NC | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.