Healthcare Provider Details

I. General information

NPI: 1437541877
Provider Name (Legal Business Name): ARISE DESTINY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 J N PEASE PL STE 101
CHARLOTTE NC
28262-4541
US

IV. Provider business mailing address

10211 MERIDALE CROSSING DR
CHARLOTTE NC
28269-7367
US

V. Phone/Fax

Practice location:
  • Phone: 704-907-8242
  • Fax: 704-973-0694
Mailing address:
  • Phone: 704-907-8242
  • 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 Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: VIVIAN AUDREY CLARK
Title or Position: LCSW/LISW-CP
Credential:
Phone: 704-907-8242