Healthcare Provider Details

I. General information

NPI: 1003609322
Provider Name (Legal Business Name): CAROLINA THERAPEUTIC SERVICES COMMUNITY DEVELOPMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 W HARRISON ST UNIT 1
CHICAGO IL
60612-3342
US

IV. Provider business mailing address

1528 UNION RD
GASTONIA NC
28054-2200
US

V. Phone/Fax

Practice location:
  • Phone: 704-864-1477
  • Fax:
Mailing address:
  • Phone: 704-864-1477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL CANCEL
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 773-698-4688