Basic Information
Provider Information | |||||||||
NPI: | 1518357953 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAVIS-LEGERTON | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MAED, LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 SAINT JOSEPH ST APT 16 | ||||||||
Address2: |   | ||||||||
City: | CAROLINA BEACH | ||||||||
State: | NC | ||||||||
PostalCode: | 284284700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107362925 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 110 BRANCHWOOD DR STE B | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285465900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109389833 | ||||||||
FaxNumber: | 9109389835 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2015 | ||||||||
LastUpdateDate: | 04/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 10388 | NC | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 10388 | NC | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.