=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104453547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASK OFF THERAPEUTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2020
-----------------------------------------------------
Last Update Date | 03/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8501 TOWER POINT DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28227-7849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-530-0245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5912 BRIGHTSTAR VALLEY RD
-----------------------------------------------------
City | MINT HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28227-7691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-530-0245
-----------------------------------------------------
Fax | 704-910-3057
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KEBA SABAN BOSLEY
-----------------------------------------------------
Credential | MSW LCSW
-----------------------------------------------------
Telephone | 203-530-0245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------