Healthcare Provider Details

I. General information

NPI: 1063753374
Provider Name (Legal Business Name): KATHLEEN AMANDA CHERRY LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 CARMEL EXECUTIVE PARK DR STE 210
CHARLOTTE NC
28226-0406
US

IV. Provider business mailing address

7401 CARMEL EXECUTIVE PARK DR STE 210
CHARLOTTE NC
28226-0406
US

V. Phone/Fax

Practice location:
  • Phone: 704-752-8414
  • Fax: 704-544-1109
Mailing address:
  • Phone: 704-752-8414
  • Fax: 704-544-1109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9612
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: