Provider Demographics
NPI:1740714559
Name:PEGRAM, CAROLINE (LCSWA, LCAS)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:LCSWA, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 TUNNEL RD STE F
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-1869
Mailing Address - Country:US
Mailing Address - Phone:828-280-8608
Mailing Address - Fax:828-774-5726
Practice Address - Street 1:119 TUNNEL RD STE F
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-1869
Practice Address - Country:US
Practice Address - Phone:828-280-8608
Practice Address - Fax:828-774-5726
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22662101YA0400X
NCP0116601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1740714559Medicaid