Provider Demographics
NPI:1902055528
Name:FLACK, ELIZABETH FAYE (LCAS, LPA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:FAYE
Last Name:FLACK
Suffix:
Gender:F
Credentials:LCAS, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 TRADD CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6637
Mailing Address - Country:US
Mailing Address - Phone:910-343-6890
Mailing Address - Fax:910-332-1233
Practice Address - Street 1:1920 TRADD CT
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6637
Practice Address - Country:US
Practice Address - Phone:910-343-6890
Practice Address - Fax:910-332-1233
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3599103TC0700X
NCLCAS-1932103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical