MEDICARE: WILLIAM JUSTIN WADSWORTH MA, LPC-A, NCC

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	A15094	NC

General Provider Information

NPI Number	:	1912541632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM JUSTIN WADSWORTH MA, LPC-A, NCC

Provider Business Mailing Address
First Line	:	3401 BRAEWICK PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-8603
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	322 LAMAR AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2436
Country	:	US
Telephone Number	:	704-425-2117
Fax Number	:

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

Provider Enumeration Date	:	11/06/2019
Last Update Date	:	11/06/2019

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