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Behavioral Health & Social Service Providers Psychologist Addiction (Substance Use Disorder)

Provider NPI: 1356369375

Provider Information:
Gender: M
Not Sole Proprietor

Practice Location:
Tel: 704-358-2700  Fax: --

Business Mailing Address:
PO BOX 19305  CHARLOTTE, NC 28219-9305 US
Tel: --  Fax: --

NPI Information:
NPI: 1356369375
Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y103TA0400XBehavioral Health & Social Service Providers
Addiction (Substance Use Disorder)

Other Provider Identifiers:


American Medical Association 2012 taxonomy code information

Code: 103TA0400X





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