| Doctor Name: | MIRIAM O'BANNON |
| NPI Number: | 1164812921 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCASA |
| License Number: | 2130A |
| Business Practice Address: | 132 Commercial Dr Suite 120 Forest City, NC - 280432400 |
| Business Phone Number: | 8282481117 |
| Business Fax Number: | |
| Mailing Address: | 4685 Hackberry Grove Cir, Apt 1827 CHARLOTTE |
| State: | NC |
| Postal Code: | 282692431 |
| Phone Number: | 7066310570 |
| Fax Number: | |
| NPI Enumeration Date: | 02/02/2015 |
| NPI Last Update Date: | 02/02/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 2130A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |