Healthcare Provider Details

I. General information

NPI: 1134033152
Provider Name (Legal Business Name): KERRY LYNN SHIPMAN PHD, CADC-R, CPSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6636 E W T HARRIS BLVD STE E
CHARLOTTE NC
28215-5125
US

IV. Provider business mailing address

6636 E W T HARRIS BLVD STE E
CHARLOTTE NC
28215-5125
US

V. Phone/Fax

Practice location:
  • Phone: 704-553-5392
  • Fax: 980-333-4063
Mailing address:
  • Phone: 704-553-5392
  • Fax: 980-333-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-28341
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: