=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841495090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CHRISTIAN COUNSELING & WELLNESS GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 01/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 REVOLUTION MILL DR # 1
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27405-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-273-8305
-----------------------------------------------------
Fax | 336-273-8308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21034
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27420-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-273-8305
-----------------------------------------------------
Fax | 336-273-8308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SARAH GRAHAM
-----------------------------------------------------
Credential | R.N., M.S.
-----------------------------------------------------
Telephone | 336-273-8305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------