MEDICARE: ASCENTIA MIND AND BODY WELLNESS CENTER, PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1205515566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASCENTIA MIND AND BODY WELLNESS CENTER, PLLC

Provider Business Mailing Address
First Line	:	1914 J N PEASE PL STE 180&182
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4504
Country	:	US
Telephone Number	:	704-909-0302
Fax Number	:	704-772-1774

Provider Business Practice Location Address
First Line	:	1914 J N PEASE PL STE 180&182
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4504
Country	:	US
Telephone Number	:	704-909-0302
Fax Number	:	704-772-1774

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	CLAUDETTE A GREEN
Credential	:	DNP PMHNP-BC
Telephone Number	:	704-909-0304

Provider Enumeration Date	:	07/14/2023
Last Update Date	:	01/19/2026

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