Provider Demographics
NPI:1730714163
Name:MAYTA, SANDRA LOURDES (LCMHC, NCC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LOURDES
Last Name:MAYTA
Suffix:
Gender:F
Credentials:LCMHC, NCC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12512 WALDEN LEA DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-2241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 FERN CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:704-821-0844
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15608101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health