Healthcare Provider Details

I. General information

NPI: 1053666834
Provider Name (Legal Business Name): CAROLINA NEUROBEHAVIORAL SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7810 BALLANTYNE COMMONS PKWY SUITE 309
CHARLOTTE NC
28277-3415
US

IV. Provider business mailing address

7810 BALLANTYNE COMMONS PKWY SUITE 300
CHARLOTTE NC
28277-3415
US

V. Phone/Fax

Practice location:
  • Phone: 704-319-5538
  • Fax: 888-703-9409
Mailing address:
  • Phone: 704-319-5538
  • Fax: 888-703-9409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4230
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4230
License Number StateNC

VIII. Authorized Official

Name: DR. LISA ANNE SWOROWSKI
Title or Position: OWNER/NEURPSYCHOLOGIST
Credential: PH.D.
Phone: 704-319-5538