Provider Demographics
NPI:1689803793
Name:COKER, NYDIAN EILEEN (MED, LPC, LCAS,NCC)
Entity Type:Individual
Prefix:MRS
First Name:NYDIAN
Middle Name:EILEEN
Last Name:COKER
Suffix:
Gender:F
Credentials:MED, LPC, LCAS,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 CHICKADEE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0669
Mailing Address - Country:US
Mailing Address - Phone:704-780-2569
Mailing Address - Fax:
Practice Address - Street 1:4601 PARK RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:704-344-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104684Medicaid