MEDICARE: EMBRACE CHABAQ MINISTRIES

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	106H00000X	Marriage & Family Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1386878601	OTHER		NPI

General Provider Information

NPI Number	:	1396316089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMBRACE CHABAQ MINISTRIES

Provider Business Mailing Address
First Line	:	8307 UNIVERSITY EXEC PARK DR STE 242
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1374
Country	:	US
Telephone Number	:	704-900-5560
Fax Number	:

Provider Business Practice Location Address
First Line	:	8307 UNIVERSITY EXEC PARK DR STE 242
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1374
Country	:	US
Telephone Number	:	704-900-5560
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST/PRESIDENT
Name	:	SANITA ANN MOULTON
Credential	:	LMFT
Telephone Number	:	704-281-4424

Provider Enumeration Date	:	07/05/2021
Last Update Date	:	07/05/2021

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