=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033958558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNIES CREATIVE COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2024
-----------------------------------------------------
Last Update Date | 05/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18407 W CATAWBA AVE 203
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-5688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-350-5486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4708 STONEY BRANCH DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28216-6611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-557-8946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MS. RINA G TUCKER
-----------------------------------------------------
Credential | LCMHC
-----------------------------------------------------
Telephone | 843-557-8946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------