MEDICARE: ANNA BREAISHA MAYES LCMHC

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	A1508	NC
2	101YP2500X	Professional Counselor	A15081	NC
3	101YM0800X	Mental Health Counselor	15081	NC

General Provider Information

NPI Number	:	1699320564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA BREAISHA MAYES LCMHC

Provider Business Mailing Address
First Line	:	PO BOX 748465
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-8465
Country	:	US
Telephone Number	:	855-284-7483
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 PARK RD STE B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3130
Country	:	US
Telephone Number	:	980-217-6901
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	05/11/2023

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