Provider Demographics
NPI:1467602334
Name:FERMIN, PRISCILLA (LCSW)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:FERMIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 EMERALD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-0631
Mailing Address - Country:US
Mailing Address - Phone:773-848-8248
Mailing Address - Fax:
Practice Address - Street 1:1900 RANDOLPH RD STE 402
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1106
Practice Address - Country:US
Practice Address - Phone:704-384-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0159061041C0700X
NCC0096081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical