Healthcare Provider Details

I. General information

NPI: 1356275259
Provider Name (Legal Business Name): CHELSEA N GWYN LCAS-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 BETHANIA RURAL HALL RD
WINSTON SALEM NC
27106-9606
US

IV. Provider business mailing address

1323 BETHANIA RURAL HALL RD
WINSTON SALEM NC
27106-9606
US

V. Phone/Fax

Practice location:
  • Phone: 336-602-5089
  • Fax: 336-602-5089
Mailing address:
  • Phone: 336-602-5089
  • Fax: 336-602-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number28746
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: