Provider Demographics
NPI:1164046728
Name:EGROFF, KEVIN THOMAS (CDAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:EGROFF
Suffix:
Gender:M
Credentials:CDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-4603
Mailing Address - Country:US
Mailing Address - Phone:980-240-4352
Mailing Address - Fax:
Practice Address - Street 1:2134 AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4603
Practice Address - Country:US
Practice Address - Phone:980-240-4352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC85-1217548Medicaid
NC85-1217548OtherBCBS NC