MEDICARE: PRESTIGE CHILDRENS TRAUMA CHILD DEVELOPMENT CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YP1600X	Pastoral Counselor
2	315P00000X	Intellectual Disabilities Intermediate Care Facility
3	106S00000X	Behavior Technician
4	251S00000X	Community/Behavioral Health Agency
5	252Y00000X	Early Intervention Provider Agency
6	305S00000X	Point of Service
7	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1427764836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE CHILDRENS TRAUMA CHILD DEVELOPMENT CORP

Provider Business Mailing Address
First Line	:	57 UNION ST S STE 1221
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28025-5009
Country	:	US
Telephone Number	:	980-292-2204
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 GLEN LAUREL DR
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28025-1614
Country	:	US
Telephone Number	:	980-219-0907
Fax Number	:

Authorized Official
Title or Position	:	PASTORAL COUNSELOR
Name	:	DR. WANDA MARIE BURNS
Credential	:
Telephone Number	:	888-779-1232

Provider Enumeration Date	:	01/30/2023
Last Update Date	:	04/25/2023

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