Healthcare Provider Details

I. General information

NPI: 1609635895
Provider Name (Legal Business Name): MENTABLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MEDICAL PLAZA DR STE 350
CHARLOTTE NC
28262-8700
US

IV. Provider business mailing address

8401 MEDICAL PLAZA DR STE 350
CHARLOTTE NC
28262-8700
US

V. Phone/Fax

Practice location:
  • Phone: 980-223-4566
  • Fax: 980-500-1522
Mailing address:
  • Phone: 877-306-1683
  • Fax: 980-500-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CAMELLIA DOUGLAS
Title or Position: OWNER/PROVIDER
Credential:
Phone: 877-306-1683