Provider Demographics
NPI:1730375577
Name:BRANSCOME, RODERICK ELI (LPCS, LCAS)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:ELI
Last Name:BRANSCOME
Suffix:
Gender:M
Credentials:LPCS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S TRYON ST
Mailing Address - Street 2:SUITE 1060
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28281-0001
Mailing Address - Country:US
Mailing Address - Phone:704-496-9757
Mailing Address - Fax:704-496-9757
Practice Address - Street 1:1801 E FIFTH ST STE 212
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3400
Practice Address - Country:US
Practice Address - Phone:704-661-1429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7077101YP2500X
SC5079101YP2500X
NC2592101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC46-5335903OtherEIN