MEDICARE: GROW YOURSELF GREAT COUNSELING AND CONSULTING 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1326646514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROW YOURSELF GREAT COUNSELING AND CONSULTING PLLC

Provider Business Mailing Address
First Line	:	3020 PROSPERITY CHURCH RD # 905
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-7197
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 J N PEASE PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4557
Country	:	US
Telephone Number	:	704-219-7306
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	INOBEME POLK
Credential	:	LCSW-A
Telephone Number	:	704-219-7306

Provider Enumeration Date	:	10/11/2020
Last Update Date	:	10/11/2020

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