Provider Demographics
NPI:1679036578
Name:PETTICE, SYNOVIA (LCAS)
Entity Type:Individual
Prefix:
First Name:SYNOVIA
Middle Name:
Last Name:PETTICE
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 1:3815 N TRYON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2060
Mailing Address - Country:US
Mailing Address - Phone:704-372-8806
Mailing Address - Fax:704-372-6920
Practice Address - Street 1:3815 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2060
Practice Address - Country:US
Practice Address - Phone:704-372-8806
Practice Address - Fax:704-372-6920
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC877101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC21286Medicaid