Healthcare Provider Details

I. General information

NPI: 1114502242
Provider Name (Legal Business Name): CAROLINAS PROFESSIONAL COUNSELING & CONSULTING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10130 MALLARD CREEK RD STE 300
CHARLOTTE NC
28262-6001
US

IV. Provider business mailing address

10130 MALLARD CREEK RD STE 300
CHARLOTTE NC
28262-6001
US

V. Phone/Fax

Practice location:
  • Phone: 704-497-2633
  • Fax: 704-625-9084
Mailing address:
  • Phone: 980-439-2672
  • Fax: 704-625-9084

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: SHELLY H SANDERS
Title or Position: LICENSED COUNSELOR/PRACTICE OWNER
Credential: LCMHC
Phone: 980-439-2672