MEDICARE: CLUB SUCCESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1023332111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLUB SUCCESS

Provider Business Mailing Address
First Line	:	6004 NUTHATCH CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-5524
Country	:	US
Telephone Number	:	980-213-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	6004 NUTHATCH CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-5524
Country	:	US
Telephone Number	:	980-213-6400
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	BALRIE PARKS
Credential	:	M.ED QMHP
Telephone Number	:	980-213-6400

Provider Enumeration Date	:	03/18/2010
Last Update Date	:	03/18/2010

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Directions to “CLUB SUCCESS ” Practice Location

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