1720131782 NPI number — MRS. SONJA R BUCKLES-SMITH LCMHCS

Table of content: MRS. SONJA R BUCKLES-SMITH LCMHCS (NPI 1720131782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720131782 NPI number — MRS. SONJA R BUCKLES-SMITH LCMHCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLES-SMITH
Provider First Name:
SONJA
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCMHCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUCKLES
Provider Other First Name:
SONJA
Provider Other Middle Name:
ROCHELLE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC, LPCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720131782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2722 IMPATIEN 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:
28215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-773-3956
Provider Business Mailing Address Fax Number:
704-919-0474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2210 CORONATION BLVD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-773-3956
Provider Business Practice Location Address Fax Number:
704-919-0474
Provider Enumeration Date:
01/20/2007

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:  S9891 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: 9891 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 9891 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 005959500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6115145 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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