Healthcare Provider Details

I. General information

NPI: 1295768943
Provider Name (Legal Business Name): PSYCHOLOGICAL SERVICES OF CHARLOTTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 J N PEASE PL SUITE 204
CHARLOTTE NC
28262-4513
US

IV. Provider business mailing address

1923 J N PEASE PL SUITE 204
CHARLOTTE NC
28262-4513
US

V. Phone/Fax

Practice location:
  • Phone: 704-503-3535
  • Fax: 704-593-5555
Mailing address:
  • Phone: 704-503-3535
  • Fax: 704-593-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3328NCLPC
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12226
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2846
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3953
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3660
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4444
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004544
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN RONALD MONTELEONE
Title or Position: PRESIDENT
Credential: PH. D.
Phone: 704-503-3535