Healthcare Provider Details

I. General information

NPI: 1023628278
Provider Name (Legal Business Name): QUADIEDRA AMOS NCC, LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 09/06/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 FAIRWAY DR
FAYETTEVILLE NC
28305-5502
US

IV. Provider business mailing address

#1298 5075 MORGANTON RD STE
FAYETTEVILLE NC
28305-0276
US

V. Phone/Fax

Practice location:
  • Phone: 910-491-8186
  • Fax: 910-808-1042
Mailing address:
  • Phone: 910-882-3878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA15615
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: