MEDICARE: THE FACTS INITIATIVE

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	:	1679128409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE FACTS INITIATIVE

Provider Business Mailing Address
First Line	:	1341 E MOREHEAD ST STE 202-B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2937
Country	:	US
Telephone Number	:	704-251-2481
Fax Number	:

Provider Business Practice Location Address
First Line	:	1341 E MOREHEAD ST STE 202-B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2937
Country	:	US
Telephone Number	:	704-251-2481
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	GWENDOLYN DIONE HARRIS
Credential	:	MA, LPCA, NCC
Telephone Number	:	309-706-9336

Provider Enumeration Date	:	08/08/2019
Last Update Date	:	08/08/2019

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Directions to “THE FACTS INITIATIVE ” Practice Location

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