Healthcare Provider Details

I. General information

NPI: 1619105988
Provider Name (Legal Business Name): OASIS CLINICAL CARE MANAGER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 IDLEWILD RD
CHARLOTTE NC
28212-0517
US

IV. Provider business mailing address

6101 IDLEWILD RD
CHARLOTTE NC
28212-0517
US

V. Phone/Fax

Practice location:
  • Phone: 704-536-8381
  • Fax:
Mailing address:
  • Phone: 704-536-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3676
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005215
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC006053
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005319
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP002725
License Number StateNC

VIII. Authorized Official

Name: MR. THEODUS ROACH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 704-604-1437