Basic Information
| Provider Information | |||||||||
| NPI: | 1619416906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | CHARLIE | ||||||||
| MiddleName: | RANDOLPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MA, LCASA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 CLANTON RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043329001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 517 CLANTON ROAD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043329001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2017 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 22826 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.