Healthcare Provider Details

I. General information

NPI: 1699148361
Provider Name (Legal Business Name): MICHELLE DERAE NEWTON-FONCHAM LCMHC, LCAS, CCS-I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

VIRTUAL ONLY
CHARLOTTE NC
28216
US

V. Phone/Fax

Practice location:
  • Phone: 980-390-7762
  • Fax: 980-301-9309
Mailing address:
  • Phone: 980-390-7762
  • Fax: 980-301-9309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11982
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-21512
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: