MEDICARE: CHARLOTTE COUNSELING AND WELLNESS CENTER, 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	101YP2500X	Professional Counselor	7193	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598083230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLOTTE COUNSELING AND WELLNESS CENTER, PLLC

Provider Business Mailing Address
First Line	:	1211 APPLEGATE PKWY
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-6726
Country	:	US
Telephone Number	:	704-256-4893
Fax Number	:	704-256-4893

Provider Business Practice Location Address
First Line	:	1811 SARDIS RD N STE 207
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-3000
Country	:	US
Telephone Number	:	757-285-0565
Fax Number	:	704-256-4893

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DIANA A MOSER-BURG
Credential	:	MHS, LPC
Telephone Number	:	704-256-4893

Provider Enumeration Date	:	05/05/2010
Last Update Date	:	05/05/2010

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