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General NPI Number Information
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NPI Number | 1023332111
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Entity Type | Organization
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Legal Business Name | CLUB SUCCESS
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Dates
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Enumeration Date | 03/18/2010
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Last Update Date | 03/18/2010
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Provider Practice Location Address
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Address Line | 6004 NUTHATCH CT
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City | CHARLOTTE
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State | NC
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Zip | 28277-5524
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Country | US
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Telephone | 980-213-6400
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Fax |
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Provider Business Mailing Address
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Address Line | 6004 NUTHATCH CT
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City | CHARLOTTE
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State | NC
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Zip | 28277-5524
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Country | US
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Telephone | 980-213-6400
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | BALRIE PARKS
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Credential | M.ED QMHP
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Telephone | 980-213-6400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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