Provider Demographics
NPI:1578394607
Name:MCILWAIN, RONALD (LCAS-A)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:MCILWAIN
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-5861
Mailing Address - Country:US
Mailing Address - Phone:704-834-9290
Mailing Address - Fax:
Practice Address - Street 1:5601 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8863
Practice Address - Country:US
Practice Address - Phone:704-537-1022
Practice Address - Fax:704-569-0822
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)