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General NPI Number Information
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NPI Number | 1457861072
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Entity Type | Organization
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Legal Business Name | PROVISIONS COUNSELING SERVICES
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Dates
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Enumeration Date | 10/10/2017
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Last Update Date | 12/06/2017
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Provider Practice Location Address
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Address Line | 1000 BAXTER ST
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City | CHARLOTTE
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State | NC
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Zip | 28204-2859
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Country | US
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Telephone | 704-750-0655
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Fax |
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Provider Business Mailing Address
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Address Line | 5115 MINTVALE DR
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City | CHARLOTTE
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State | NC
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Zip | 28269-1689
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Country | US
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Telephone | 704-750-0655
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. SHIRICKA LASHAYE FAIR
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Credential | PHD, LMFT
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Telephone | 704-750-0655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 1484
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 1484
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License Number State | NC
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