Basic Information
| Provider Information | |||||||||
| NPI: | 1942785068 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METASPACE COUNSELING PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2504 NEWINGTON CT | ||||||||
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| City: | CLEMMONS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270128673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363920477 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 OLD MILL CIR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271032977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369970408 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2018 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | OVERSTREET | ||||||||
| AuthorizedOfficialFirstName: | ALEXIS | ||||||||
| AuthorizedOfficialMiddleName: | N/A | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 3363920477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW, LCAS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.