MEDICARE: IMPACT CAROLINA SERVICES, INC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	795	NC
2	101YP2500X	Professional Counselor	5171	NC
3	1041C0700X	Clinical Social Worker	C001664	NC
4	363LA2200X	Adult Health Nurse Practitioner	0600071	NC
5	2084P0800X	Psychiatry Physician	NC 2005-00391	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619285756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT CAROLINA SERVICES, INC

Provider Business Mailing Address
First Line	:	2848 QUEEN CITY DR STE G
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-2739
Country	:	US
Telephone Number	:	704-405-1617
Fax Number	:	704-405-1619

Provider Business Practice Location Address
First Line	:	2848 QUEEN CITY DR STE G
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-2739
Country	:	US
Telephone Number	:	704-405-1617
Fax Number	:	704-405-1619

Authorized Official
Title or Position	:	DIRECTOR/CEO
Name	:	DR. JOSEPH ADEDOKUN
Credential	:	PH.D.
Telephone Number	:	704-405-1617

Provider Enumeration Date	:	09/23/2010
Last Update Date	:	09/23/2010

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Directions to “IMPACT CAROLINA SERVICES, INC ” Practice Location

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