1225623499 NPI number — MR. EDEM MATTHIAS EXCELLENCE MS, LCSW-A

Table of content: MR. EDEM MATTHIAS EXCELLENCE MS, LCSW-A (NPI 1225623499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225623499 NPI number — MR. EDEM MATTHIAS EXCELLENCE MS, LCSW-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EXCELLENCE
Provider First Name:
EDEM
Provider Middle Name:
MATTHIAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS, LCSW-A
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:
1225623499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11125 HAZEL GARDENS DRIVE
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:
28278-7942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-416-3025
Provider Business Mailing Address Fax Number:
980-448-3419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
432 EAST LONG AVENUE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-2540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-416-3025
Provider Business Practice Location Address Fax Number:
980-448-3419
Provider Enumeration Date:
03/09/2021

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:  P015897 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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