1639983109 NPI number — SYDNEY ELLESSE KAUFFMAN LCMHC-A

Table of content: SYDNEY ELLESSE KAUFFMAN LCMHC-A (NPI 1639983109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639983109 NPI number — SYDNEY ELLESSE KAUFFMAN LCMHC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAUFFMAN
Provider First Name:
SYDNEY
Provider Middle Name:
ELLESSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCMHC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAIN
Provider Other First Name:
SYDNEY
Provider Other Middle Name:
ELLESSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCMHC-A
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639983109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2728 WINGDALE 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:
28213-5269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-424-7768
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1933 JAKE ALEXANDER BLVD W STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28147-1157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-762-0074
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2025

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:  A20686 , 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)





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