Provider Demographics
NPI:1477214641
Name:KINGSLEY ROAD COUNSELING AND CONSULTING GROUP, PLLC
Entity Type:Organization
Organization Name:KINGSLEY ROAD COUNSELING AND CONSULTING GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-285-3952
Mailing Address - Street 1:3431 SELWYN FARMS LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-4030
Mailing Address - Country:US
Mailing Address - Phone:980-285-3952
Mailing Address - Fax:
Practice Address - Street 1:6747 FAIRVIEW RD STE C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3359
Practice Address - Country:US
Practice Address - Phone:980-285-3952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty