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NPI Code Detail

MEDICARE: KINTSUGI COUNSELING PROFESSIONAL LIMITED LIABILITY COMPANY

MEDICARE: KINTSUGI COUNSELING PROFESSIONAL LIMITED LIABILITY COMPANY
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
11041C0700XClinical Social Worker

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11689191983OTHERNPI FOR PRIVATE INSURANCE
21962854505OTHERNPI FOR PRIVATE INSURANCE

General Provider Information

NPI Number : 1679114102
Entity Type Code : Organization
Provider Name (Legal Business Name) : KINTSUGI COUNSELING PROFESSIONAL LIMITED LIABILITY COMPANY
Provider Business Mailing Address
First Line : 1403 EASTCREST DR APT 202
Second Line :
City : CHARLOTTE
State : NC
Zip : 28205-8277
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 322 LAMAR AVE STE 209
Second Line :
City : CHARLOTTE
State : NC
Zip : 28204-2436
Country : US
Telephone Number : 704-644-9613
Fax Number :
Authorized Official
Title or Position : OWNER THERAPIST
Name : NAOMI DE LA CRUZ SPENCER
Credential :
Telephone Number : 704-644-9613
Provider Enumeration Date : 10/07/2019
Last Update Date : 10/07/2019

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Directions to “KINTSUGI COUNSELING PROFESSIONAL LIMITED LIABILITY COMPANY ” Practice Location

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