Healthcare Provider Details

I. General information

NPI: 1386312155
Provider Name (Legal Business Name): AUSTIN TYLER NEDVED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2021
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 MEETING ST
INDIAN TRAIL NC
28079-6582
US

IV. Provider business mailing address

10315 MONROVIA DR APT 308
MATTHEWS NC
28105-5578
US

V. Phone/Fax

Practice location:
  • Phone: 980-292-1793
  • Fax:
Mailing address:
  • Phone: 336-409-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-26493
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16185
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: