Healthcare Provider Details

I. General information

NPI: 1679234017
Provider Name (Legal Business Name): WINGS OF FLIGHT CENTER FOR CHANGE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 EBENEZER RD
OLD FORT NC
28762-7846
US

IV. Provider business mailing address

118 EBENEZER RD
OLD FORT NC
28762-7846
US

V. Phone/Fax

Practice location:
  • Phone: 828-407-0880
  • Fax:
Mailing address:
  • Phone: 828-407-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRANDI LYNN HARRIS
Title or Position: OWNER/THERAPIST
Credential: MA, LCMHCS
Phone: 828-407-0880