MEDICARE: SPORTSSMARTS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	103TE1100X	Exercise & Sports Psychologist
3	1041C0700X	Clinical Social Worker
4	251S00000X	Community/Behavioral Health Agency
5	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1861778102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTSSMARTS

Provider Business Mailing Address
First Line	:	4401 E INDEPENDENCE BLVD
Second Line	:	SUITE 201B
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7485
Country	:	US
Telephone Number	:	704-248-0514
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 E INDEPENDENCE BLVD
Second Line	:	SUITE 201B
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7485
Country	:	US
Telephone Number	:	704-248-0514
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	AHMAD BLAKENEY
Credential	:
Telephone Number	:	704-248-0514

Provider Enumeration Date	:	11/01/2011
Last Update Date	:	11/01/2011

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Directions to “SPORTSSMARTS ” Practice Location

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