Basic Information
Provider Information | |||||||||
NPI: | 1821343815 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OVERACRE | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOLNAR | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 35 MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | PINEHURST | ||||||||
State: | NC | ||||||||
PostalCode: | 283748708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102359090 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 35 MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | PINEHURST | ||||||||
State: | NC | ||||||||
PostalCode: | 283748708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107153376 | ||||||||
FaxNumber: | 9107155391 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2012 | ||||||||
LastUpdateDate: | 04/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 002441 | CT | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | C013833 | NC | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | P014431 | 01 | NC | LCSW-A | OTHER |