Healthcare Provider Details

I. General information

NPI: 1629630876
Provider Name (Legal Business Name): VISIONARY PASSAGE COUNSELING AND CONSULTATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E 6TH ST STE 2A
CHARLOTTE NC
28202-2918
US

IV. Provider business mailing address

3520 SIMMONS ST
CHARLOTTE NC
28208-4754
US

V. Phone/Fax

Practice location:
  • Phone: 704-612-0180
  • Fax:
Mailing address:
  • Phone: 704-726-4862
  • 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 TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MONIQUE HEATH
Title or Position: CLINICAL DIRECTOR
Credential: LPC, LCAS, CCS-I
Phone: 704-612-0180