Healthcare Provider Details

I. General information

NPI: 1780492876
Provider Name (Legal Business Name): GEWYL TUCKER MINISTRIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 GAELIC DR
STATESVILLE NC
28625-2833
US

IV. Provider business mailing address

242 OAK AVE UNIT 142
KANNAPOLIS NC
28081-4329
US

V. Phone/Fax

Practice location:
  • Phone: 980-221-9927
  • Fax:
Mailing address:
  • Phone: 980-221-9927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. GEWYL TUCKER
Title or Position: MANAGING MEMBER
Credential: LCMHC
Phone: 980-330-2215