Healthcare Provider Details

I. General information

NPI: 1477331213
Provider Name (Legal Business Name): EXPERT OF LIVED EXPERIENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8539 MONROE RD # 105
CHARLOTTE NC
28212-7510
US

IV. Provider business mailing address

8539 MONROE RD STE 105
CHARLOTTE NC
28212-7510
US

V. Phone/Fax

Practice location:
  • Phone: 704-817-8814
  • Fax: 888-706-9896
Mailing address:
  • Phone: 704-817-8814
  • Fax: 888-706-9896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 12
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: VERNELL TAMIKA MACKIE
Title or Position: OPERATION EXECUTIVE CEO
Credential: CART,CPLC,CDVS,CCTS
Phone: 704-817-8814