Provider Demographics
NPI:1548796766
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
Authorized Official - Prefix:
Authorized Official - First Name:JAMARR
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNDERBURG
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:704-771-4633
Mailing Address - Street 1:1905 J N PEASE PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4557
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:2017-05-08
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106481041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1167535Medicaid