MEDICARE: ONE:12 COUNSELING PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor
3	106H00000X	Marriage & Family Therapist
4	101Y00000X	Counselor

General Provider Information

NPI Number	:	1184264178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE:12 COUNSELING PLLC

Provider Business Mailing Address
First Line	:	7751 BALLANTYNE COMMONS PKWY STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-2442
Country	:	US
Telephone Number	:	704-626-6550
Fax Number	:	704-626-6550

Provider Business Practice Location Address
First Line	:	7751 BALLANTYNE COMMONS PKWY STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-2442
Country	:	US
Telephone Number	:	704-626-6550
Fax Number	:	704-626-6550

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	KELLY TAYLOR
Credential	:
Telephone Number	:	704-502-7969

Provider Enumeration Date	:	01/08/2020
Last Update Date	:	01/08/2020

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