MEDICARE: SOUTHEAST CHILD & FAMILY GUIDANCE, 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1356629273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST CHILD & FAMILY GUIDANCE, PLLC

Provider Business Mailing Address
First Line	:	105 WAXHAW PROFESSIONAL PARK DR STE H
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-5018
Country	:	US
Telephone Number	:	704-770-8049
Fax Number	:	704-256-9968

Provider Business Practice Location Address
First Line	:	105 WAXHAW PROFESSIONAL PARK DR STE H
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-5018
Country	:	US
Telephone Number	:	704-770-8049
Fax Number	:	704-256-9968

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	KATHLEEN BREADY
Credential	:	LCMHC
Telephone Number	:	704-770-8049

Provider Enumeration Date	:	07/26/2011
Last Update Date	:	04/04/2024

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