=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831930908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NU GENERATION MENTAL HEALTH SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2024
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 GREEN VALLEY RD STE 200
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-2156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-278-3666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 OLD TREYBROOKE DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-8145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-278-3666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TASHA LATIL BURNETTE
-----------------------------------------------------
Credential | LCMHC
-----------------------------------------------------
Telephone | 540-278-3666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------