Healthcare Provider Details

I. General information

NPI: 1558100636
Provider Name (Legal Business Name): FULL CIRCLE WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6416 CARMEL RD STE 408
CHARLOTTE NC
28226-8268
US

IV. Provider business mailing address

3908 ASHTON DR
CHARLOTTE NC
28210-6844
US

V. Phone/Fax

Practice location:
  • Phone: 980-428-9174
  • Fax:
Mailing address:
  • Phone: 919-619-7379
  • 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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TONIA JACOBS DEESE
Title or Position: OWNER, DIRECTOR
Credential: MSW, LCSW
Phone: 919-619-7379