Basic Information
| Provider Information | |||||||||
| NPI: | 1487194692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BYRD | ||||||||
| FirstName: | KATRICE | ||||||||
| MiddleName: | LACHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCULLUM | ||||||||
| OtherFirstName: | KATRICE | ||||||||
| OtherMiddleName: | LACHELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442668268 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 335 N CASWELL RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847980 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2017 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P011010 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C011982 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.