=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477214641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGSLEY ROAD COUNSELING AND CONSULTING GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2022
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6747 FAIRVIEW RD STE C
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-3359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-285-3952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3431 SELWYN FARMS LN
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28209-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-285-3952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ANN CLAY CHURCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 980-285-3952
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------