=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205327004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPYQUEST, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2018
-----------------------------------------------------
Last Update Date | 05/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6845 FAIRVIEW RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-266-2069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1435
-----------------------------------------------------
City | BELMONT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28012-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORGANIZER
-----------------------------------------------------
Name | STACEY MICHELLE CRUZ
-----------------------------------------------------
Credential | LCMHC, LCAS
-----------------------------------------------------
Telephone | 704-266-2069
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 9838
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------