Healthcare Provider Details

I. General information

NPI: 1376465450
Provider Name (Legal Business Name): ANNA GRACE WYRICK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20501 N MAIN ST
CORNELIUS NC
28031-8460
US

IV. Provider business mailing address

709 NORTHEAST DR STE 22
DAVIDSON NC
28036-7425
US

V. Phone/Fax

Practice location:
  • Phone: 704-912-4095
  • Fax:
Mailing address:
  • Phone: 704-912-4095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP023947
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: