MEDICARE: CONVERSION THERAPEUTIC 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1194588616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONVERSION THERAPEUTIC SERVICES INC

Provider Business Mailing Address
First Line	:	848 KATHY DIANNE DR
Second Line	:
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-6898
Country	:	US
Telephone Number	:	443-531-1988
Fax Number	:

Provider Business Practice Location Address
First Line	:	11535 CARMEL COMMONS BLVD STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-5314
Country	:	US
Telephone Number	:	704-910-1788
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TENICIA WASHINGTON
Credential	:	PMHNP, FNP, CRNP
Telephone Number	:	443-531-1988

Provider Enumeration Date	:	02/06/2024
Last Update Date	:	10/08/2024

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