Healthcare Provider Details

I. General information

NPI: 1992985972
Provider Name (Legal Business Name): SHEENA ILEAN HASTY LCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 E INNES ST
SALISBURY NC
28146-6030
US

IV. Provider business mailing address

665 W 4TH ST
WINSTON SALEM NC
27101-2701
US

V. Phone/Fax

Practice location:
  • Phone: 704-633-3616
  • Fax:
Mailing address:
  • Phone: 336-725-8389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number28287
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: