Provider Demographics
NPI:1144274572
Name:CANUP, ALICE L (LCSW)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:L
Last Name:CANUP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3336
Mailing Address - Country:US
Mailing Address - Phone:704-365-7777
Mailing Address - Fax:704-365-9256
Practice Address - Street 1:6809 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3336
Practice Address - Country:US
Practice Address - Phone:704-365-7777
Practice Address - Fax:704-365-9256
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC002378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2873218Medicare ID - Type Unspecified