Provider Demographics
NPI:1154558724
Name:GBAUM
Entity type:Organization
Organization Name:GBAUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMILA
Authorized Official - Middle Name:SAFIYA
Authorized Official - Last Name:NETTLES-FELDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:803-984-0124
Mailing Address - Street 1:5111 NATIONS CROSSING RD
Mailing Address - Street 2:BUILDING 8 SUITE 226
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-2126
Mailing Address - Country:US
Mailing Address - Phone:803-984-0124
Mailing Address - Fax:704-504-5021
Practice Address - Street 1:5111 NATIONS CROSSING RD
Practice Address - Street 2:BUILDING 8 SUITE 226
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-2126
Practice Address - Country:US
Practice Address - Phone:803-984-0124
Practice Address - Fax:704-504-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5431251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103628Medicaid