MEDICARE: MS. LAURIE AMY JACHYM L.C.S.W.

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	1041C0700X	Clinical Social Worker	C006129	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C006129	OTHER	NC	SOCIAL WORK CERTIFICATION AND LICENSURE BOARD (LCSW)
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841342185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURIE AMY JACHYM L.C.S.W.

Provider Business Mailing Address
First Line	:	811 CENTRAL AVE
Second Line	:	SUITE 7
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2032
Country	:	US
Telephone Number	:	704-575-0626
Fax Number	:	704-612-8204

Provider Business Practice Location Address
First Line	:	811 CENTRAL AVE
Second Line	:	SUITE 7
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2032
Country	:	US
Telephone Number	:	704-575-0626
Fax Number	:	704-612-8204

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	08/01/2011

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