Healthcare Provider Details

I. General information

NPI: 1144794637
Provider Name (Legal Business Name): BHWC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9130 UNIVERSITY CITY BLVD
CHARLOTTE NC
28213-2821
US

IV. Provider business mailing address

3024 CONE MANOR LN
RALEIGH NC
27613-6604
US

V. Phone/Fax

Practice location:
  • Phone: 704-559-9865
  • Fax: 888-519-4656
Mailing address:
  • Phone: 510-776-3984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MARLIN METTERS
Title or Position: OWNER
Credential:
Phone: 510-776-3984