=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245094192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONVERSION THERAPEUTIC SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2024
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11535 CARMEL COMMONS BLVD STE 102
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28226-5314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-910-1788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 848 KATHY DIANNE DR
-----------------------------------------------------
City | INDIAN LAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29707-6898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-531-1988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TENICIA WASHINGTON
-----------------------------------------------------
Credential | PMHNP, FNP, CRNP
-----------------------------------------------------
Telephone | 443-531-1988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------