Provider Demographics
NPI:1275788119
Name:CHILD & FAMILY THERAPY CENTER, PC
Entity Type:Organization
Organization Name:CHILD & FAMILY THERAPY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:WRIGHT
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LMFT, PHD
Authorized Official - Phone:704-664-7148
Mailing Address - Street 1:363 WILLIAMSON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5973
Mailing Address - Country:US
Mailing Address - Phone:704-664-7148
Mailing Address - Fax:704-664-3086
Practice Address - Street 1:363 WILLIAMSON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5973
Practice Address - Country:US
Practice Address - Phone:704-664-7148
Practice Address - Fax:704-664-3086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC000914101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2862897AMedicare UPIN