Healthcare Provider Details

I. General information

NPI: 1306315064
Provider Name (Legal Business Name): MATTHEW EADDY MSW, LCSW-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2018
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 SARDIS RD N
CHARLOTTE NC
28227-7715
US

IV. Provider business mailing address

2300 SARDIS ROAD N
CHARLOTTE NC
28227
US

V. Phone/Fax

Practice location:
  • Phone: 704-344-0491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP013019
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: