Healthcare Provider Details

I. General information

NPI: 1841576287
Provider Name (Legal Business Name): SHELLEY ALICEA LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 COX RD
GASTONIA NC
28054-0628
US

IV. Provider business mailing address

515 CLANTON RD
CHARLOTTE NC
28217-1309
US

V. Phone/Fax

Practice location:
  • Phone: 704-865-1558
  • Fax: 704-865-9908
Mailing address:
  • Phone: 704-332-9001
  • Fax: 704-332-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1901
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: