Healthcare Provider Details

I. General information

NPI: 1013821412
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP NC COASTAL REGION SPECIALTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 VILLAGE RD STE 104
SHALLOTTE NC
28470-3409
US

IV. Provider business mailing address

PO BOX 604532
CHARLOTTE NC
28260-4532
US

V. Phone/Fax

Practice location:
  • Phone: 910-721-4200
  • Fax: 910-754-3811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LEEA JEANINE WALTON
Title or Position: RCS MANAGER
Credential:
Phone: 704-316-6081