Provider Demographics
NPI:1891312930
Name:MACILWINEN, BRIAN PEACE
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:PEACE
Last Name:MACILWINEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 LATROBE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5226
Mailing Address - Country:US
Mailing Address - Phone:704-780-4271
Mailing Address - Fax:704-788-2016
Practice Address - Street 1:3000 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5226
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:704-788-2016
Is Sole Proprietor?:No
Enumeration Date:2020-07-05
Last Update Date:2020-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCBVR102684513OtherBLUE CROSS BLUE SHIELD