Healthcare Provider Details

I. General information

NPI: 1275821597
Provider Name (Legal Business Name): THERAPEUTIC INTERVENTION GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S MINT ST SUITE 108
CHARLOTTE NC
28203-4049
US

IV. Provider business mailing address

1100 S MINT ST SUITE 108
CHARLOTTE NC
28203-4049
US

V. Phone/Fax

Practice location:
  • Phone: 704-927-9695
  • Fax:
Mailing address:
  • Phone: 704-927-9695
  • Fax: 704-927-9697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CARLTON GUNNING
Title or Position: OWNER
Credential:
Phone: 704-927-9695