Provider Demographics
NPI:1417386566
Name:ELMORE, JERRY TIMOTHY (LCAS-A)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:TIMOTHY
Last Name:ELMORE
Suffix:
Gender:M
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 1:631 BRAWLEY SCHOOL RD
Mailing Address - Street 2:STE 200B PMB 301
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6208
Mailing Address - Country:US
Mailing Address - Phone:704-884-2060
Mailing Address - Fax:704-854-4860
Practice Address - Street 1:2505 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-884-2060
Practice Address - Fax:704-854-4860
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3527A101YA0400X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)