Provider Demographics
NPI:1396283669
Name:BAUER, DESTINY NICOLE (LPCA)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:NICOLE
Last Name:BAUER
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N MARION DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7613
Mailing Address - Country:US
Mailing Address - Phone:919-581-7720
Mailing Address - Fax:919-587-0007
Practice Address - Street 1:1503 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-2203
Practice Address - Country:US
Practice Address - Phone:919-587-0001
Practice Address - Fax:919-587-0007
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA122778101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor