Healthcare Provider Details

I. General information

NPI: 1245194141
Provider Name (Legal Business Name): K'NETHA MESHUN FAGGART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 DEBRA CIR SW
CONCORD NC
28025-8992
US

IV. Provider business mailing address

8500 AMETHYST LN NW APT 11210
CHARLOTTE NC
28262-5074
US

V. Phone/Fax

Practice location:
  • Phone: 980-331-4031
  • Fax:
Mailing address:
  • Phone: 980-331-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: