{
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"NPI": "1144705815",
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"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PERRY WELLNESS COUNSELING, PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
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"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 25923",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHARLOTTE",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "28229-5923",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "980-270-1939",
"MailingAddressFaxNumber": "980-270-4557",
"FirstLinePracticeLocationAddress": "6733 FAIRVIEW RD STE B",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHARLOTTE",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "28210-3652",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "980-270-1939",
"PracticeLocationAddressFaxNumber": "980-270-4557",
"EnumerationDate": "09/28/2018",
"LastUpdateDate": "02/20/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PERRY",
"AuthorizedOfficialFirstName": "CHERYL",
"AuthorizedOfficialMiddleName": "D",
"AuthorizedOfficialTitle": "OWNER/CLINICIAN",
"AuthorizedOfficialNamePrefix": "MS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MA LCMHCA NCC",
"AuthorizedOfficialTelephoneNumber": "980-270-1939",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM0850X",
"TaxonomyName": "Adult Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}