=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083395339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEAR FOUNDATIONS THERAPY AND ASSESSMENT PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2023
-----------------------------------------------------
Last Update Date | 07/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5113 PIPER STATION DR STE 104
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-6652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-378-8595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5113 PIPER STATION DR STE 104
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-6652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | STEPHANIE GOODSON
-----------------------------------------------------
Credential | MS, LPA
-----------------------------------------------------
Telephone | 704-837-2473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------