Healthcare Provider Details

I. General information

NPI: 1215672456
Provider Name (Legal Business Name): FLOURISH FOUNDATION PROJECT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9107 CARROT PATCH DR
CHARLOTTE NC
28216-7103
US

IV. Provider business mailing address

9107 CARROT PATCH DR
CHARLOTTE NC
28216-7103
US

V. Phone/Fax

Practice location:
  • Phone: 704-661-3005
  • Fax:
Mailing address:
  • Phone: 704-661-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHANDA L SPATES
Title or Position: CEO
Credential:
Phone: 704-661-3005