MEDICARE: METANOIA MIND AND WELLNESS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063213908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METANOIA MIND AND WELLNESS PLLC

Provider Business Mailing Address
First Line	:	11 CONCORD COMMONS PL SW STE A16
Second Line	:	STE 1013
City	:	CONCORD
State	:	NC
Zip	:	28027
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1558 UNION RD STE A
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-2215
Country	:	US
Telephone Number	:	704-323-6513
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATONJA PICKETT
Credential	:	LCSW
Telephone Number	:	980-225-2880

Provider Enumeration Date	:	03/24/2025
Last Update Date	:	03/24/2025

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