1982798179 NPI number — MRS. COSSANDRA EVETTE MILLER LCSW

Table of content: MRS. COSSANDRA EVETTE MILLER LCSW (NPI 1982798179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982798179 NPI number — MRS. COSSANDRA EVETTE MILLER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
COSSANDRA
Provider Middle Name:
EVETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1982798179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1426 JUNIPER HILLS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29707-7740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-763-9555
Provider Business Mailing Address Fax Number:
704-532-5948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4822 ALBEMARLE RD STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28205-6612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-763-9555
Provider Business Practice Location Address Fax Number:
704-532-5948
Provider Enumeration Date:
10/03/2006

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: 101YM0800X , with the licence number:  C005101 , 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: 6106146 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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