Healthcare Provider Details

I. General information

NPI: 1235054891
Provider Name (Legal Business Name): ELIJAH ROACH LCAS A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10348 PARK RD
CHARLOTTE NC
28210-8507
US

IV. Provider business mailing address

10348 PARK RD
CHARLOTTE NC
28210-8507
US

V. Phone/Fax

Practice location:
  • Phone: 704-288-1097
  • Fax:
Mailing address:
  • Phone: 704-288-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number31576
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: