MEDICARE: COTSWOLD CLINICIAN SUPPORT SERVICES

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	101Y00000X	Counselor
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063893568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COTSWOLD CLINICIAN SUPPORT SERVICES

Provider Business Mailing Address
First Line	:	447 S SHARON AMITY RD
Second Line	:	STE 250
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2889
Country	:	US
Telephone Number	:	704-264-2973
Fax Number	:	980-498-6700

Provider Business Practice Location Address
First Line	:	447 S SHARON AMITY RD
Second Line	:	STE 250
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2889
Country	:	US
Telephone Number	:	704-264-2973
Fax Number	:	980-498-6700

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. KIMBERLY MATONE
Credential	:	LCMHC
Telephone Number	:	704-493-4934

Provider Enumeration Date	:	06/11/2015
Last Update Date	:	05/05/2025

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