Provider Demographics
NPI:1073979878
Name:JEFFCOAT, TOMMY LAMAR (LCASA)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:LAMAR
Last Name:JEFFCOAT
Suffix:
Gender:M
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 SHARVIEW CIR
Mailing Address - Street 2:APT. 1332
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-6630
Mailing Address - Country:US
Mailing Address - Phone:803-979-2821
Mailing Address - Fax:
Practice Address - Street 1:515 CLANTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1309
Practice Address - Country:US
Practice Address - Phone:980-242-2744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)