1548341084 NPI number — MR. JEFFREY LAFORGE MSW, LCSW

Table of content: MR. JEFFREY LAFORGE MSW, LCSW (NPI 1548341084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548341084 NPI number — MR. JEFFREY LAFORGE MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAFORGE
Provider First Name:
JEFFREY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
M

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:
1548341084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 HIGH BROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAXHAW
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-674-4898
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
608 MATTHEWS MINT HILL RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-1756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-674-4898
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2006

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: 1041C0700X , with the licence number:  C004995 , 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: 510546568 . This is a "CIGNA PROVIDER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7651956 . This is a "AETNA PROVIDER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: C004995 . This is a "SOC WORK LICENSE NUM" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6106088 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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