Provider Demographics
NPI:1952406845
Name:KIDS CENTRAL OF THE CAROLINAS, LLC
Entity Type:Organization
Organization Name:KIDS CENTRAL OF THE CAROLINAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR / LICENSED PSYCOL
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMILAH
Authorized Official - Middle Name:MCPHAIL
Authorized Official - Last Name:MCKISSICK
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:980-214-4281
Mailing Address - Street 1:617 N. SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216
Mailing Address - Country:US
Mailing Address - Phone:704-369-2502
Mailing Address - Fax:704-688-2961
Practice Address - Street 1:4722 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:704-369-2502
Practice Address - Fax:704-688-2961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016N5OtherBCBSNC
NC6005230Medicaid
NC6005230Medicaid