Healthcare Provider Details

I. General information

NPI: 1477298362
Provider Name (Legal Business Name): SHANTE DENISE GREGORY LCMCHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/04/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 UNIONVILLE INDIAN TRAIL RD W
INDIAN TRAIL NC
28079-5665
US

IV. Provider business mailing address

13663 PROVIDENCE RD # 355
WEDDINGTON NC
28104-9373
US

V. Phone/Fax

Practice location:
  • Phone: 704-438-9901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA14915
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: