=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447824677
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QUADASHA D MCILWAINE MSW, LCSW, LISW-CP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2021
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 648 S JONES AVE STE B
-----------------------------------------------------
City | ROCK HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29730-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-909-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3824 PIMILICO TRACE LN
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28216-7803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-909-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C013792
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------