1114647013 NPI number — CEDRIC DEAN CPP

Table of content: TRISH ANN BLOSS LMSW (NPI 1285884957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114647013 NPI number — CEDRIC DEAN CPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEAN
Provider First Name:
CEDRIC
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEAN
Provider Other First Name:
CEDRIC
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1114647013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5502 MCCHESNEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28269-7188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-492-5509
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1712 S LAFAYETTE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28152-7151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-492-5509
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2022

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: 171WH0202X , with the licence number:  2021877201 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 405300000X , with the licence number: 2021877201 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000005049292 . This is a "DMV" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1497473086 . This is a "PRIVATE INSURANCE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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