Healthcare Provider Details

I. General information

NPI: 1811204217
Provider Name (Legal Business Name): NORTH CAROLINA NEUROPSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 SHANNON WILLOW RD STE 400
CHARLOTTE NC
28226-1350
US

IV. Provider business mailing address

6911 SHANNON WILLOW RD STE 400
CHARLOTTE NC
28226-1350
US

V. Phone/Fax

Practice location:
  • Phone: 980-296-2211
  • Fax: 984-235-1617
Mailing address:
  • Phone: 980-296-2211
  • Fax: 984-235-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY CLARK
Title or Position: ADMINISTRATOR
Credential:
Phone: 919-785-5055