Provider Demographics
NPI:1366913345
Name:CONWAY, MONIQUE ANCHELLE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:ANCHELLE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 QUAIL HIGH BLVD
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7024
Mailing Address - Country:US
Mailing Address - Phone:301-704-7618
Mailing Address - Fax:919-683-1790
Practice Address - Street 1:800 N MANGUM ST STE 400
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2260
Practice Address - Country:US
Practice Address - Phone:919-683-1607
Practice Address - Fax:919-683-1790
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-23045101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)