Provider Demographics
NPI:1083058101
Name:BANKS, MERCIDA HAMPTON (LCAS-A)
Entity Type:Individual
Prefix:
First Name:MERCIDA
Middle Name:HAMPTON
Last Name:BANKS
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:284 EXECUTIVE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1833
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3209-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3209-AOtherPROVISIONAL LICENSED
NC101YA0400XMedicaid