Provider Demographics
NPI:1861824682
Name:ICENHOUR, CHRISTOPHER DANIEL (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DANIEL
Last Name:ICENHOUR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:
Other - Last Name:ICENHOUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:1400 WILLOW LN
Practice Address - Street 2:
Practice Address - City:N WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3551
Practice Address - Country:US
Practice Address - Phone:336-667-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0114641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1861824682Medicaid
NC19G4XOtherBCBS