Provider Demographics
NPI:1407310063
Name:SHELL, REBECCA WILSON (LCAS-A)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:WILSON
Last Name:SHELL
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 1:2016 NOLEN PARK LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1565
Mailing Address - Country:US
Mailing Address - Phone:704-756-7688
Mailing Address - Fax:
Practice Address - Street 1:200 QUEENS RD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3252
Practice Address - Country:US
Practice Address - Phone:704-756-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCASA25106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)