Basic Information
| Provider Information | |||||||||
| NPI: | 1205804705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIMMERMAN | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | MARJORIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 132 POPLAR GROVE CONNECTOR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282648759 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 POPLAR GROVE CONNECTOR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282648759 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1110 | NC | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6105114 | 05 | NC | MEDICAID | 141AA | 01 | NC | BCBS OF NC | OTHER |