Provider Demographics
NPI:1417495474
Name:MENTAL HEALTH & SPIRITUAL WELLNESS THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:MENTAL HEALTH & SPIRITUAL WELLNESS THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PSYCHOTHERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TYNECCA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:704-231-9025
Mailing Address - Street 1:213-D SOUTH TRADE STREET
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4564
Mailing Address - Country:US
Mailing Address - Phone:704-231-9025
Mailing Address - Fax:
Practice Address - Street 1:213-D S TRADE STREET
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4866
Practice Address - Country:US
Practice Address - Phone:704-231-9025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0068111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1316262975Medicaid