Basic Information
| Provider Information | |||||||||
| NPI: | 1225363401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SILLS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NCC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 PEE DEE AVE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049861500 | ||||||||
| FaxNumber: | 3362246393 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 GRIMES BLVD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272927640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362246071 | ||||||||
| FaxNumber: | 3362246393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2009 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 9077 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6115106 | 05 | NC | MEDICAID |