=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518366137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOLA SANFORD LPCA, MFTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2014
-----------------------------------------------------
Last Update Date | 08/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4232 SHOPTON RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28217-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-880-5247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8230 GLAMORGAN LN
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28104-0643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-880-5247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A10632
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------