MEDICARE: CLINICIANS OF MECKLENBURG

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	175T00000X	Peer Specialist
2	251S00000X	Community/Behavioral Health Agency
3	101YP1600X	Pastoral Counselor
4	101YP2500X	Professional Counselor
5	101YS0200X	School Counselor
6	101Y00000X	Counselor
7	101YA0400X	Addiction (Substance Use Disorder) Counselor
8	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174099436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICIANS OF MECKLENBURG

Provider Business Mailing Address
First Line	:	11 UNION ST S # LL207
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28025-5059
Country	:	US
Telephone Number	:	919-672-5005
Fax Number	:	800-806-0750

Provider Business Practice Location Address
First Line	:	11 UNION ST S # LL207
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28025-5059
Country	:	US
Telephone Number	:	919-672-5005
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. DASHUN BANKS
Credential	:	LPC
Telephone Number	:	919-672-5005

Provider Enumeration Date	:	10/15/2018
Last Update Date	:	06/06/2022

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Directions to “CLINICIANS OF MECKLENBURG ” Practice Location

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