Healthcare Provider Details

I. General information

NPI: 1326781170
Provider Name (Legal Business Name): CHANEL PATRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 E W T HARRIS BLVD STE 109-440
CHARLOTTE NC
28215-3541
US

IV. Provider business mailing address

5820 E W T HARRIS BLVD STE 109-440
CHARLOTTE NC
28215-3541
US

V. Phone/Fax

Practice location:
  • Phone: 704-559-9830
  • Fax:
Mailing address:
  • Phone: 704-559-9830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-272922
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC16318
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17960
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: