MEDICARE: QUADIEDRA AMOS NCC, LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A15615	NC

General Provider Information

NPI Number	:	1023628278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUADIEDRA AMOS NCC, LCMHC

Provider Business Mailing Address
First Line	:	#1298 5075 MORGANTON RD STE
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-0276
Country	:	US
Telephone Number	:	910-882-3878
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 FAIRWAY DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-5502
Country	:	US
Telephone Number	:	910-491-8186
Fax Number	:	910-808-1042

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2020
Last Update Date	:	09/06/2022

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