Healthcare Provider Details

I. General information

NPI: 1508842923
Provider Name (Legal Business Name): LEADERSHIP AND RESILIENCE CONSULTANTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2005
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FOREST RIDGE DR
FORT MILL SC
29715-6418
US

IV. Provider business mailing address

15105D JOHN J DELANEY DR STE 192
CHARLOTTE NC
28277-2741
US

V. Phone/Fax

Practice location:
  • Phone: 803-543-7617
  • Fax: 800-858-2194
Mailing address:
  • Phone: 704-769-0660
  • Fax: 800-858-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT000954G
License Number StateGA

VIII. Authorized Official

Name: MRS. KIMBERLY LANNETTE WILSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LMFT
Phone: 704-769-0660