Healthcare Provider Details

I. General information

NPI: 1598083230
Provider Name (Legal Business Name): CHARLOTTE COUNSELING AND WELLNESS CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 SARDIS RD N STE 207
CHARLOTTE NC
28270-3000
US

IV. Provider business mailing address

1211 APPLEGATE PKWY
WAXHAW NC
28173-6726
US

V. Phone/Fax

Practice location:
  • Phone: 757-285-0565
  • Fax: 704-256-4893
Mailing address:
  • Phone: 704-256-4893
  • Fax: 704-256-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7193
License Number StateNC

VIII. Authorized Official

Name: DIANA A MOSER-BURG
Title or Position: SOLE PROPRIETOR
Credential: MHS, LPC
Phone: 704-256-4893