MEDICARE: IVY COUNSELING AND THERAPUETIC SERVICES

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	251S00000X	Community/Behavioral Health Agency		NC

General Provider Information

NPI Number	:	1861744054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVY COUNSELING AND THERAPUETIC SERVICES

Provider Business Mailing Address
First Line	:	6600 ROSE POINT LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-1990
Country	:	US
Telephone Number	:	704-231-8313
Fax Number	:

Provider Business Practice Location Address
First Line	:	7013 PAWTUCKETT RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-2232
Country	:	US
Telephone Number	:	704-231-8313
Fax Number	:

Authorized Official
Title or Position	:	CO-EXECUTIVE DIRECTOR
Name	:	MISS CYNTHIA MICHELLE MCKNIGHT
Credential	:
Telephone Number	:	704-231-8313

Provider Enumeration Date	:	10/11/2012
Last Update Date	:	10/11/2012

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