Basic Information
| Provider Information | |||||||||
| NPI: | 1962669689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STURDIVANT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 895 STATE FARM RD | ||||||||
| Address2: | SUITE 508 | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286074917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282635666 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 HWY 18 SOUTH | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286758478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363724095 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6838 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.