Provider Demographics
NPI:1720004054
Name:EADS, CONNIE L (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:EADS
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 1:501 BILLINGSLEY ROAD
Mailing Address - Street 2:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1009
Mailing Address - Country:US
Mailing Address - Phone:704-358-2700
Mailing Address - Fax:704-358-2938
Practice Address - Street 1:501 BILLINGSLEY ROAD
Practice Address - Street 2:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-358-2700
Practice Address - Fax:704-358-2716
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0032011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003556Medicaid