Healthcare Provider Details

I. General information

NPI: 1669305645
Provider Name (Legal Business Name): CREATE YOUR OWN LEGACY EMPOWERMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16316 OLD STONE CROSSING DR
CHARLOTTE NC
28213-4923
US

IV. Provider business mailing address

16316 OLD STONE CROSSING DR
CHARLOTTE NC
28213-4923
US

V. Phone/Fax

Practice location:
  • Phone: 216-501-9618
  • Fax:
Mailing address:
  • Phone: 216-501-9618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DAMON L GORDON
Title or Position: OWNER
Credential:
Phone: 216-501-9618