Organization
OASIS CLINICAL CARE MANAGER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. THEODUS ROACH (EXECUTIVE DIRECTOR)
(704) 604-1437
Entity
Organization
Contact information
Practice address
6101 IDLEWILD RD, CHARLOTTE, NC 28212-0517
(704) 536-8381
Mailing address
6101 IDLEWILD RD, CHARLOTTE, NC 28212-0517
(704) 536-8381
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
3676
NC
1041C0700X
Clinical Social Worker
C005215
NC
1041C0700X
Clinical Social Worker
C005319
NC
1041C0700X
Clinical Social Worker
C006053
NC
1041C0700X
Clinical Social Worker
P002725
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2011974
—
NC
05
—
6106359
—
NC
05
—
6106363
—
NC
05
—
6107588
—
NC
05
—
89133JF
—
NC
Enumeration date
06/25/2009
Last updated
06/25/2009
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