Healthcare Provider Details

I. General information

NPI: 1477173201
Provider Name (Legal Business Name): 3C WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9711 DAVID TAYLOR DR
CHARLOTTE NC
28262-2366
US

IV. Provider business mailing address

11752 PRIDELAND CT
CHARLOTTE NC
28273-4612
US

V. Phone/Fax

Practice location:
  • Phone: 704-565-9578
  • Fax:
Mailing address:
  • Phone: 704-713-9600
  • 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
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY SHAW
Title or Position: OWNER / THERAPIST
Credential:
Phone: 704-713-9600