MEDICARE: THE VILLAGE BEHAVIORAL HEALTHCARE SERVICES, INC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	3040	NC
2	1041C0700X	Clinical Social Worker
3	1041C0700X	Clinical Social Worker	C009966	NC

General Provider Information

NPI Number	:	1164878880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VILLAGE BEHAVIORAL HEALTHCARE SERVICES, INC

Provider Business Mailing Address
First Line	:	3126 MILTON RD STE 233
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-3782
Country	:	US
Telephone Number	:	704-891-3481
Fax Number	:	855-299-3536

Provider Business Practice Location Address
First Line	:	3126 MILTON RD STE 233
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-3782
Country	:	US
Telephone Number	:	704-817-9117
Fax Number	:	855-299-3536

Authorized Official
Title or Position	:	OWNER, CLINICAL THERAPIST
Name	:	MALIK ASHHALI
Credential	:	MSW, LCSW, LCAS, CCS
Telephone Number	:	704-891-3481

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	04/06/2022

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