1063631331 NPI number — LATASHA SHAWNTAY MCILWAINE MA, MHA, LPC, LCAS

Table of content: LATASHA SHAWNTAY MCILWAINE MA, MHA, LPC, LCAS (NPI 1063631331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063631331 NPI number — LATASHA SHAWNTAY MCILWAINE MA, MHA, LPC, LCAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCILWAINE
Provider First Name:
LATASHA
Provider Middle Name:
SHAWNTAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, MHA, LPC, LCAS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063631331
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAW CREEK
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28130-0743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-340-4666
Provider Business Mailing Address Fax Number:
704-969-7298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 EAST BLVD
Provider Second Line Business Practice Location Address:
SUITE 6B
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28203-5817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-340-4666
Provider Business Practice Location Address Fax Number:
704-969-7298
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 6691 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 1296 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6103719 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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