Basic Information
| Provider Information | |||||||||
| NPI: | 1073857124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | THOMAS PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCMHC, LCASA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610-A S. COLLEGE ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107962490 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Practice Location | |||||||||
| Address1: | 610-A S. COLLEGE ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107962490 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 21403 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 9687 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 21403 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 9687 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.