MEDICARE: CHILD & FAMILY THERAPY CENTER PC

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	101YP2500X	Professional Counselor	851	NC

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	:	1396074159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILD & FAMILY THERAPY CENTER PC

Provider Business Mailing Address
First Line	:	363 WILLIAMSON RD
Second Line	:	SUITE 102
City	:	MOORESVILLE
State	:	NC
Zip	:	28117-5974
Country	:	US
Telephone Number	:	704-664-7148
Fax Number	:	704-664-3086

Provider Business Practice Location Address
First Line	:	715 FAIRGROVE CHURCH RD SE
Second Line	:	SUITE 102
City	:	CONOVER
State	:	NC
Zip	:	28613-9290
Country	:	US
Telephone Number	:	704-664-7148
Fax Number	:	704-664-3086

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. PAMELA H JAMES
Credential	:
Telephone Number	:	704-664-7148

Provider Enumeration Date	:	12/08/2009
Last Update Date	:	03/03/2015

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