MEDICARE: ANN CLAY CHURCH MA

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	101YP2500X	Professional Counselor	A12542	NC

General Provider Information

NPI Number	:	1720588783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANN CLAY CHURCH MA

Provider Business Mailing Address
First Line	:	7804 FAIRVIEW RD STE C288
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4998
Country	:	US
Telephone Number	:	980-295-3952
Fax Number	:

Provider Business Practice Location Address
First Line	:	7804 FAIRVIEW RD STE C288
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4998
Country	:	US
Telephone Number	:	980-285-3952
Fax Number	:

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

Provider Enumeration Date	:	02/16/2018
Last Update Date	:	08/13/2019

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Directions to “ ANN CLAY CHURCH MA” Practice Location

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