Healthcare Provider Details

I. General information

NPI: 1053755934
Provider Name (Legal Business Name): ALISAHA'S HOME CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 AINSWORTH ST
CHARLOTTE NC
28216-3693
US

IV. Provider business mailing address

8221 AINSWORTH ST
CHARLOTTE NC
28216-3693
US

V. Phone/Fax

Practice location:
  • Phone: 704-957-1846
  • Fax: 704-599-2915
Mailing address:
  • Phone: 704-957-1846
  • Fax: 704-599-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number192299
License Number StateNC

VIII. Authorized Official

Name: MRS. LISA MARIE HARDEN
Title or Position: CEO/MANAGER
Credential:
Phone: 704-957-1846