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General NPI Number Information
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NPI Number | 1619105988
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Entity Type | Organization
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Legal Business Name | OASIS CLINICAL CARE MANAGER, LLC
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Dates
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Enumeration Date | 06/25/2009
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Last Update Date | 06/25/2009
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Provider Practice Location Address
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Address Line | 6101 IDLEWILD RD
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City | CHARLOTTE
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State | NC
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Zip | 28212-0517
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Country | US
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Telephone | 704-536-8381
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Fax |
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Provider Business Mailing Address
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Address Line | 6101 IDLEWILD RD
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City | CHARLOTTE
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State | NC
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Zip | 28212-0517
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Country | US
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Telephone | 704-536-8381
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. THEODUS ROACH
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Credential |
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Telephone | 704-604-1437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C005215
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C006053
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C005319
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License Number State | NC
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | P002725
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License Number State | NC
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Taxonomy #5
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3676
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License Number State | NC
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