1770851388 NPI number — BE WHOLE COUNSELING AND WELLNESS SERVICES, PLLC

Table of content: (NPI 1770851388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770851388 NPI number — BE WHOLE COUNSELING AND WELLNESS SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BE WHOLE COUNSELING AND WELLNESS SERVICES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770851388
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10506 GROBIE WAY APT 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28216-0251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-733-7475
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9635 SOUTHERN PINE BLVD STE 124
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-733-7475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
REDDICK-UMOJA
Authorized Official First Name:
ISIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR/THERAPIST
Authorized Official Telephone Number:
704-733-7475

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  5341 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6103236 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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