Healthcare Provider Details

I. General information

NPI: 1679344972
Provider Name (Legal Business Name): EAGLES WILL NC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 MOCKINGBIRD LN STE 420
CHARLOTTE NC
28209-3236
US

IV. Provider business mailing address

1413 38TH ST
BROOKLYN NY
11218-3613
US

V. Phone/Fax

Practice location:
  • Phone: 917-648-4292
  • Fax:
Mailing address:
  • Phone: 917-648-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL FISCHMAN
Title or Position: CEO
Credential:
Phone: 917-648-4292