MEDICARE: FULL CIRCLE 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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053153254	OTHER	NC	NPI

General Provider Information

NPI Number	:	1558100636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL CIRCLE WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	3908 ASHTON DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-6844
Country	:	US
Telephone Number	:	919-619-7379
Fax Number	:

Provider Business Practice Location Address
First Line	:	6416 CARMEL RD STE 408
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-8268
Country	:	US
Telephone Number	:	980-428-9174
Fax Number	:

Authorized Official
Title or Position	:	OWNER, DIRECTOR
Name	:	MRS. TONIA JACOBS DEESE
Credential	:	MSW, LCSW
Telephone Number	:	919-619-7379

Provider Enumeration Date	:	05/20/2024
Last Update Date	:	02/06/2025

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Directions to “FULL CIRCLE WELLNESS, PLLC ” Practice Location

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