Provider Demographics
NPI:1699255059
Name:MEACHUM, RALPH GORDON (MDIV, CSAC)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:GORDON
Last Name:MEACHUM
Suffix:
Gender:M
Credentials:MDIV, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9918 BARRANDS LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-8030
Mailing Address - Country:US
Mailing Address - Phone:336-588-5513
Mailing Address - Fax:
Practice Address - Street 1:10348 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8507
Practice Address - Country:US
Practice Address - Phone:704-288-1097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC-15131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)