Healthcare Provider Details

I. General information

NPI: 1952749921
Provider Name (Legal Business Name): DIEDRE MONIQUE FISHER LCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MOORESVILLE RD
KANNAPOLIS NC
28081-0304
US

IV. Provider business mailing address

100 BILLINGSLEY RD
CHARLOTTE NC
28211-1002
US

V. Phone/Fax

Practice location:
  • Phone: 704-920-1205
  • Fax: 704-934-4270
Mailing address:
  • Phone: 704-927-8798
  • Fax: 704-376-3384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3352
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3352
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: