Healthcare Provider Details

I. General information

NPI: 1467782177
Provider Name (Legal Business Name): CHARLOTTE COUNSELING AND CONSULTING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 02/26/2024
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 J N PEASE PL STE 202
CHARLOTTE NC
28262-4539
US

IV. Provider business mailing address

3602 NEWCHURCH CIR
CHARLOTTE NC
28269-7702
US

V. Phone/Fax

Practice location:
  • Phone: 704-771-4633
  • Fax: 980-225-5555
Mailing address:
  • Phone: 704-771-4633
  • Fax: 980-225-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1184
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC005599
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberC005599
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005599
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberC005599
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JAMARR J FUNDERBURG
Title or Position: OWNER/THERAPIST
Credential: LCSW, LCAS, CCS,
Phone: 704-771-4633