Healthcare Provider Details

I. General information

NPI: 1457861072
Provider Name (Legal Business Name): PROVISIONS COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BAXTER ST
CHARLOTTE NC
28204-2859
US

IV. Provider business mailing address

5115 MINTVALE DR
CHARLOTTE NC
28269-1689
US

V. Phone/Fax

Practice location:
  • Phone: 704-750-0655
  • Fax:
Mailing address:
  • Phone: 704-750-0655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1484
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1484
License Number StateNC

VIII. Authorized Official

Name: DR. SHIRICKA LASHAYE FAIR
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD, LMFT
Phone: 704-750-0655