Healthcare Provider Details

I. General information

NPI: 1942862552
Provider Name (Legal Business Name): EDH1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9027 TIBBLE CREEK WAY
CHARLOTTE NC
28227-6670
US

IV. Provider business mailing address

9027 TIBBLE CREEK WAY
CHARLOTTE NC
28227-6670
US

V. Phone/Fax

Practice location:
  • Phone: 980-297-0703
  • Fax:
Mailing address:
  • Phone: 980-297-0703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. ELSTON DERREK HOOPER
Title or Position: OWNER
Credential:
Phone: 980-297-0703