MEDICARE: AVENUES TO SUCCESS, INC.

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1649434267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUES TO SUCCESS, INC.

Provider Business Mailing Address
First Line	:	5009 BEATTIES FORD RD STE 107-308
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2859
Country	:	US
Telephone Number	:	540-819-7342
Fax Number	:

Provider Business Practice Location Address
First Line	:	4822 ALBEMARLE RD STE 220
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6612
Country	:	US
Telephone Number	:	540-819-7342
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MYISHA WILLIS
Credential	:	MA
Telephone Number	:	540-819-7342

Provider Enumeration Date	:	07/13/2008
Last Update Date	:	07/13/2008

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