Provider Demographics
NPI:1639421670
Name:SAMPLE-RAGGINS, EDNA DANIELLE (LCAS)
Entity Type:Individual
Prefix:MS
First Name:EDNA
Middle Name:DANIELLE
Last Name:SAMPLE-RAGGINS
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:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:BARIUM SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28010-0001
Mailing Address - Country:US
Mailing Address - Phone:704-832-2200
Mailing Address - Fax:
Practice Address - Street 1:209 BARIUM SPRINGS DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-8454
Practice Address - Country:US
Practice Address - Phone:704-832-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-14
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2654A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)