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General NPI Number Information
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NPI Number | 1598250300
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Entity Type | Organization
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Legal Business Name | HEARTWOOD PERFORMANCE, PLLC
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Dates
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Enumeration Date | 06/25/2018
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Last Update Date | 09/13/2021
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Provider Practice Location Address
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Address Line | 5960 FAIRVIEW RD STE 400
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City | CHARLOTTE
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State | NC
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Zip | 28210-3119
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Country | US
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Telephone | 704-476-5575
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Fax |
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Provider Business Mailing Address
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Address Line | 15720 BRIXHAM HILL AVE
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City | CHARLOTTE
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State | NC
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Zip | 28277-4651
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Country | US
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Telephone | 704-476-5575
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BENJAMIN FOODMAN
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Credential | LSCW
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Telephone | 704-418-1333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C010390
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License Number State | NC
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