Healthcare Provider Details

I. General information

NPI: 1023332111
Provider Name (Legal Business Name): CLUB SUCCESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6004 NUTHATCH CT
CHARLOTTE NC
28277-5524
US

IV. Provider business mailing address

6004 NUTHATCH CT
CHARLOTTE NC
28277-5524
US

V. Phone/Fax

Practice location:
  • Phone: 980-213-6400
  • Fax:
Mailing address:
  • Phone: 980-213-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: BALRIE PARKS
Title or Position: EXECUTIVE DIRECTOR
Credential: M.ED QMHP
Phone: 980-213-6400