Basic Information
| Provider Information | |||||||||
| NPI: | 1568530996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOTEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2187 | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287792187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286313973 | ||||||||
| FaxNumber: | 8286319280 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 BROADVIEW RD | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287863466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286313973 | ||||||||
| FaxNumber: | 8286319280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2006 | ||||||||
| LastUpdateDate: | 05/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 3518 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 3518 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 1267 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | A9679 | 01 | NC | MEDCOST | OTHER | 2206813 | 01 | NC | CIGNA | OTHER | 1387J | 01 | NC | BCBSNC | OTHER | 6102226 | 05 | NC | MEDICAID |