Basic Information
Provider Information | |||||||||
NPI: | 1104243617 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KNOTTS | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | CLAY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LCMHC, LCAS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 284 EXECUTIVE PARK DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280251894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049391100 | ||||||||
FaxNumber: | 7049391173 | ||||||||
Practice Location | |||||||||
Address1: | 227 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | NC | ||||||||
PostalCode: | 273713058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9105723681 | ||||||||
FaxNumber: | 9105725579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2014 | ||||||||
LastUpdateDate: | 06/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-21612 | NC | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 10342 | NC | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 1104243617 | 01 | NC | HUMANA | OTHER | 19GSU | 01 | NC | BCBS | OTHER | 6001137-581 | 01 | NC | MAGELLAN | OTHER | 1104243617 | 05 | NC |   | MEDICAID |