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NPI Code Detail

MEDICARE: SYNOVIA PETTICE LCAS

MEDICARE: SYNOVIA PETTICE LCAS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor877NC
2101Y00000XCounselor877NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1679036578
Entity Type Code : Individual
Provider Name (Legal Business Name) : SYNOVIA PETTICE LCAS
Provider Business Mailing Address
First Line : 3815 N TRYON ST
Second Line :
City : CHARLOTTE
State : NC
Zip : 28206-2060
Country : US
Telephone Number : 704-372-8806
Fax Number : 704-372-6920
Provider Business Practice Location Address
First Line : 3815 N TRYON ST
Second Line :
City : CHARLOTTE
State : NC
Zip : 28206-2060
Country : US
Telephone Number : 704-372-8806
Fax Number : 704-372-6920
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/09/2019
Last Update Date : 04/09/2019

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Directions to “ SYNOVIA PETTICE LCAS” Practice Location

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