Provider Demographics
NPI:1427272863
Name:PHELPS, LOU ANN
Entity type:Individual
Prefix:
First Name:LOU
Middle Name:ANN
Last Name:PHELPS
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 1:6015 FAYETTEVILLE RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6254
Mailing Address - Country:US
Mailing Address - Phone:919-323-8081
Mailing Address - Fax:919-572-0004
Practice Address - Street 1:6050 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-8601
Practice Address - Country:US
Practice Address - Phone:919-870-8699
Practice Address - Fax:919-870-8544
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC600358Medicaid
NC600358Medicaid