MEDICARE: CHELSEA N GWYN LCAS-A

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	28746	NC

General Provider Information

NPI Number	:	1356275259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHELSEA N GWYN LCAS-A

Provider Business Mailing Address
First Line	:	1323 BETHANIA RURAL HALL RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-9606
Country	:	US
Telephone Number	:	336-602-5089
Fax Number	:	336-602-5089

Provider Business Practice Location Address
First Line	:	1323 BETHANIA RURAL HALL RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-9606
Country	:	US
Telephone Number	:	336-602-5089
Fax Number	:	336-602-5089

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2026
Last Update Date	:	06/09/2026

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