NPIMap

Organization Active NPI

Chrysalis Center for Counseling and Eating Disorder Treatment PLLC

  • Psychologist
  • Wilmington, NC
National Provider Identifier
1891865218
Registry record updated Aug 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
License
2805 Issued in NC
Legal business name
CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC
Practice address
3240 Burnt Mill Dr Ste 1
Wilmington, NC 28403-2570
Phone
(910) 790-9500
Fax
(910) 796-8111
NPI assigned
Nov 9, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 21, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Macon Funderburk
Title
Office Manager
Phone
(910) 790-9500

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X 2805 NC Primary
Counseling PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC1900X LPC6828 NC
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X C006434 NC
Registered DietitianGroup: 193200000X MULTI-SPECIALTY GROUP 133V00000X L003399 NC

Addresses

Primary practice location

3240 Burnt Mill Dr Ste 1
Wilmington, NC 28403-2570

Mailing address

3240 Burnt Mill Dr Ste 101
Wilmington, NC 28403-2576
Phone (910) 790-9500

Other identifiers 2

IdentifierTypeStateIssuer
355080OtherNCMHN/TRICARE
018AMOtherNCBCBS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100114000432 NC Part B Supplier - Clinic/Group Practice 4183765068 Receives reassigned benefits from 7 practitioners
Practice locations: Wilmington, NC

National Provider Directory

National Provider Directory
Tax ID family
Chrysalis Center for Counseling and Eating Disorder Treatment PLLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3904 Oleander Dr
Ste 101
Wilmington, NC 28403
Phone (910) 313-3232

3240 Burnt Mill Dr
Wilmington, NC 28403
Phone (910) 763-5355

3240 Burnt Mill Dr
Ste 101
Wilmington, NC 28403

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163030400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724198400000",
    "number": "1891865218",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3240 BURNT MILL DR STE 101",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284032576",
            "telephone_number": "910-790-9500",
            "fax_number": "910-796-8111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3240 BURNT MILL DR STE 1",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284032570",
            "telephone_number": "910-790-9500",
            "fax_number": "910-796-8111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-09",
        "last_updated": "2024-08-21",
        "certification_date": "2024-08-21",
        "status": "A",
        "authorized_official_last_name": "FUNDERBURK",
        "authorized_official_first_name": "MACON",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "910-790-9500"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": "NC",
            "license": "2805",
            "primary": true
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": "NC",
            "license": "LPC6828",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "NC",
            "license": "C006434",
            "primary": false
        },
        {
            "code": "133V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dietitian, Registered",
            "state": "NC",
            "license": "L003399",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MHN/TRICARE",
            "identifier": "355080",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "018AM",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wilmington, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.