MEDICARE: 3C WELLNESS, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1477173201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	3C WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	11752 PRIDELAND CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-4612
Country	:	US
Telephone Number	:	704-713-9600
Fax Number	:

Provider Business Practice Location Address
First Line	:	9711 DAVID TAYLOR DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-2366
Country	:	US
Telephone Number	:	704-565-9578
Fax Number	:

Authorized Official
Title or Position	:	OWNER / THERAPIST
Name	:	ASHLEY SHAW
Credential	:
Telephone Number	:	704-713-9600

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	04/22/2020

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