Healthcare Provider Details

I. General information

NPI: 1407629769
Provider Name (Legal Business Name): WILHELMENA CONSULTANT AND RESEARCH AGENCY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 BEATTIES FORD RD STE 107-114
CHARLOTTE NC
28216-2859
US

IV. Provider business mailing address

5009 BEATTIES FORD RD STE 107-114
CHARLOTTE NC
28216-2859
US

V. Phone/Fax

Practice location:
  • Phone: 704-891-5694
  • Fax:
Mailing address:
  • Phone: 704-891-5694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QA0900X
TaxonomyAmputee Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. THERESA WILHELMENA MCCORMICK-DUNLAP
Title or Position: CLINICAL THERAPIST
Credential: MSW, LCSW
Phone: 704-891-5694