Provider Demographics
NPI:1467782177
Name:CHARLOTTE COUNSELING AND CONSULTING, PLLC
Entity Type:Organization
Organization Name:CHARLOTTE COUNSELING AND CONSULTING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMARR
Authorized Official - Middle Name:J
Authorized Official - Last Name:FUNDERBURG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCAS, CCS,
Authorized Official - Phone:704-771-4633
Mailing Address - Street 1:3602 NEWCHURCH CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7702
Mailing Address - Country:US
Mailing Address - Phone:704-771-4633
Mailing Address - Fax:980-225-5555
Practice Address - Street 1:1905 J N PEASE PL STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4539
Practice Address - Country:US
Practice Address - Phone:704-771-4633
Practice Address - Fax:980-225-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1184101YA0400X
NCC005599101YM0800X, 103K00000X, 1041C0700X, 251S00000X
320800000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106615Medicaid