Provider Demographics
NPI:1417072828
Name:WOOTEN, DAWN R (LPC)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:R
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 EAGLES NEST RD
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-8879
Mailing Address - Country:US
Mailing Address - Phone:252-353-8452
Mailing Address - Fax:252-353-8457
Practice Address - Street 1:150 E ARLINGTON BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5019
Practice Address - Country:US
Practice Address - Phone:252-353-8452
Practice Address - Fax:252-353-8457
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4744101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102173Medicaid