Provider Demographics
NPI:1184672198
Name:AUSTIN, THOMAS GLENN (CSAC, CCS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GLENN
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:CSAC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 BONANZA RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8969
Mailing Address - Country:US
Mailing Address - Phone:704-561-0920
Mailing Address - Fax:704-561-0851
Practice Address - Street 1:5601 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8841
Practice Address - Country:US
Practice Address - Phone:704-561-0920
Practice Address - Fax:704-561-0851
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1181101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110525Medicaid