Provider Demographics
NPI:1508293242
Name:BARNETTE, PHYLLIS (LCAS)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BARNETTE
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 43686
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-1985
Mailing Address - Country:US
Mailing Address - Phone:704-231-1469
Mailing Address - Fax:704-568-6587
Practice Address - Street 1:5421 COBURG AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-2203
Practice Address - Country:US
Practice Address - Phone:704-231-1469
Practice Address - Fax:704-568-6587
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2109101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)