Healthcare Provider Details

I. General information

NPI: 1689752651
Provider Name (Legal Business Name): CAROLINA CENTER FOR COUNSELING & CLINICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 WILMOT DR
GASTONIA NC
28054-4048
US

IV. Provider business mailing address

PO BOX 550178
GASTONIA NC
28055-0178
US

V. Phone/Fax

Practice location:
  • Phone: 704-861-2234
  • Fax: 704-861-2235
Mailing address:
  • Phone: 704-861-2234
  • Fax: 704-861-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. LYNN HAMMONTREE
Title or Position: FINANCE DIRECTOR
Credential: BA
Phone: 704-861-2234