Healthcare Provider Details

I. General information

NPI: 1033924493
Provider Name (Legal Business Name): CHELSEA MENARD MA SSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

4012 PARK RD STE 200
CHARLOTTE NC
28209-2378
US

IV. Provider business mailing address

4012 PARK RD STE 200
CHARLOTTE NC
28209-2378
US

V. Phone/Fax

Practice location:
  • Phone: 704-332-4834
  • Fax:
Mailing address:
  • Phone: 704-332-4834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6710
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: