MEDICARE: DR. TERESA SIRES MCILWAIN DOCTOR OF MINISTRY

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	101YP1600X	Pastoral Counselor	80	NC

General Provider Information

NPI Number	:	1962781344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERESA SIRES MCILWAIN DOCTOR OF MINISTRY

Provider Business Mailing Address
First Line	:	3325 WASHBURN AVE STE 121
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7024
Country	:	US
Telephone Number	:	704-370-7501
Fax Number	:	704-335-1047

Provider Business Practice Location Address
First Line	:	3325 WASHBURN AVE STE 121
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7024
Country	:	US
Telephone Number	:	704-370-7501
Fax Number	:	704-335-1047

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

Provider Enumeration Date	:	08/16/2011
Last Update Date	:	08/16/2011

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