Basic Information
| Provider Information | |||||||||
| NPI: | 1437167673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLEOD ADDICTIVE DISEASE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 CLANTON RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043329001 | ||||||||
| FaxNumber: | 7043325903 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 CLANTON RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043329001 | ||||||||
| FaxNumber: | 7043325903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7043329001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MHL-059-024 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | MHL-049-101 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | MHL-060-010 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | MHL-060-880 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | MHL-036-100 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | MHL-018-057 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | MHL-095-036 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | 1208 | NC | N | Agencies | Community/Behavioral Health | 251S00000X | 1209 | NC | N | Agencies | Community/Behavioral Health | 251S00000X | MHL-060-1206 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300412 | 05 | NC | MEDICAID | 8300516 | 05 | NC | MEDICAID | 8300666 | 05 | NC | MEDICAID | 8301309 | 05 | NC | MEDICAID | 8301345 | 05 | NC | MEDICAID | 8301102 | 05 | NC | MEDICAID |