Healthcare Provider Details

I. General information

NPI: 1023872454
Provider Name (Legal Business Name): TAILORED PSYCHIATRIC WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2818 QUEEN CITY DR STE E
CHARLOTTE NC
28208-2736
US

IV. Provider business mailing address

205 N MICHIGAN AVE
CHICAGO IL
60601-5927
US

V. Phone/Fax

Practice location:
  • Phone: 623-294-8804
  • Fax:
Mailing address:
  • Phone: 623-294-8804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TONIA WALLACE
Title or Position: OWNER
Credential:
Phone: 623-294-8804