Healthcare Provider Details

I. General information

NPI: 1326950361
Provider Name (Legal Business Name): CELESTIAL PROVISIONS: THERAPY & WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S COLLEGE ST STE 152
CHARLOTTE NC
28202-1827
US

IV. Provider business mailing address

501 S COLLEGE ST STE 152
CHARLOTTE NC
28202-1827
US

V. Phone/Fax

Practice location:
  • Phone: 216-712-2237
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TIERRA DANIELLE BACON
Title or Position: MENTAL HEALTH THERAPIST
Credential: LCSW
Phone: 216-712-2237