=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649761974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR CONSCIOUS CHANGE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2018
-----------------------------------------------------
Last Update Date | 05/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 COPPERFIELD BLVD NE
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28025-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-729-4767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1614 PAT GARRETT ST
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28206-2187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-368-3684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DEBRA NEISLER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 919-368-3684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C006216
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------