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General NPI Number Information
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NPI Number | 1760710412
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Entity Type | Organization
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Legal Business Name | ICHEP OF CHARLOTTE, LLC
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Dates
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Enumeration Date | 11/18/2009
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 9635 SOUTHERN PINE BLVD SUITE 126
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City | CHARLOTTE
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State | NC
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Zip | 28273-5558
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Country | US
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Telephone | 704-749-3808
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Fax |
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Provider Business Mailing Address
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Address Line | 9635 SOUTHERN PINE BLVD SUITE 126
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City | CHARLOTTE
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State | NC
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Zip | 28273-5558
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. SHAKA MOUSTAFA
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Credential |
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Telephone | 704-749-3808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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