Provider Demographics
NPI:1548341084
Name:LAFORGE, JEFFREY (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:LAFORGE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 HIGH BROOK DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173
Mailing Address - Country:US
Mailing Address - Phone:704-674-4898
Mailing Address - Fax:
Practice Address - Street 1:608 MATTHEWS MINT HILL RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-1756
Practice Address - Country:US
Practice Address - Phone:704-674-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0049951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC510546568OtherCIGNA PROVIDER ID
NC7651956OtherAETNA PROVIDER ID
NCC004995OtherSOC WORK LICENSE NUM
NC6106088Medicaid