Healthcare Provider Details

I. General information

NPI: 1043098585
Provider Name (Legal Business Name): GREAT ROSE COUNSELING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UNION ST S STE LL228
CONCORD NC
28025-5059
US

IV. Provider business mailing address

13032 GRAYMIST DR
CHARLOTTE NC
28215-6030
US

V. Phone/Fax

Practice location:
  • Phone: 704-791-0611
  • Fax:
Mailing address:
  • Phone: 704-791-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK ANTHONY STURGIS JR.
Title or Position: OWNER
Credential: LCAS, LCMHCA, CSI
Phone: 704-791-0611