Provider Demographics
NPI:1871201228
Name:EA CLINICAL MULTISERVICES, PLLC
Entity type:Organization
Organization Name:EA CLINICAL MULTISERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELBA
Authorized Official - Middle Name:I
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-LCAS
Authorized Official - Phone:718-644-3542
Mailing Address - Street 1:401 HAWTHORNE LN STE 110-115
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2484
Mailing Address - Country:US
Mailing Address - Phone:704-396-3292
Mailing Address - Fax:
Practice Address - Street 1:401 HAWTHORNE LN STE 110-115
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2484
Practice Address - Country:US
Practice Address - Phone:704-396-3292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC176080Medicaid
SCSW1464Medicaid