Basic Information
Provider Information
NPI: 1003003039
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BARINE
FirstName: MARY
MiddleName: MUTHONI
NamePrefix: MRS.
NameSuffix:  
Credential: LPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 916 WINDEMERE LN
Address2:  
City: WAKE FOREST
State: NC
PostalCode: 275879562
CountryCode: US
TelephoneNumber: 9195627713
FaxNumber:  
Practice Location
Address1: 916 WINDEMERE LN
Address2:  
City: WAKE FOREST
State: NC
PostalCode: 275879562
CountryCode: US
TelephoneNumber: 9195627713
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/03/2007
LastUpdateDate: 05/27/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X6689NCY Behavioral Health & Social Service ProvidersCounselorMental Health

ID Information
IDTypeStateIssuerDescription
610371505NC MEDICAID


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