Healthcare Provider Details

I. General information

NPI: 1558335679
Provider Name (Legal Business Name): CAROLINAS COUNSELING GROUP OF CHARLOTTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 CARMEL EXECUTIVE PARK DR SUITE 210
CHARLOTTE NC
28226-8275
US

IV. Provider business mailing address

7401 CARMEL EXECUTIVE PARK DR SUITE 210
CHARLOTTE NC
28226-8275
US

V. Phone/Fax

Practice location:
  • Phone: 704-752-8414
  • Fax: 704-752-8104
Mailing address:
  • Phone: 704-752-8414
  • Fax: 704-752-8104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2886
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2266
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number994
License Number StateNC

VIII. Authorized Official

Name: DR. DAVID A RUSS
Title or Position: PRESIDENT
Credential: PH.D
Phone: 704-752-8414