Healthcare Provider Details

I. General information

NPI: 1164432365
Provider Name (Legal Business Name): BAIBA P PUKJANIS-GRASMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 LATROBE DR
CHARLOTTE NC
28211-4851
US

IV. Provider business mailing address

3303 LATROBE DR
CHARLOTTE NC
28211-4851
US

V. Phone/Fax

Practice location:
  • Phone: 704-362-2663
  • Fax: 704-362-2836
Mailing address:
  • Phone: 704-362-2663
  • Fax: 704-362-2836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004602
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: