Provider Demographics
NPI:1619384583
Name:INNER TRANSFORMATION THERAPEUTIC SERVICES, PLLC
Entity Type:Organization
Organization Name:INNER TRANSFORMATION THERAPEUTIC SERVICES, PLLC
Other - Org Name:INNER TRANSFORMATION THERAPEUTIC SERVICES, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORRELIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LISW-CP, LCAS
Authorized Official - Phone:980-230-8880
Mailing Address - Street 1:10130 PERIMETER PARKWAY SUITE 200 - #0425
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216
Mailing Address - Country:US
Mailing Address - Phone:980-230-8880
Mailing Address - Fax:844-841-1302
Practice Address - Street 1:10130 PERIMETER PARKWAY SUITE 200 - #0425
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216
Practice Address - Country:US
Practice Address - Phone:980-230-8880
Practice Address - Fax:844-841-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-12
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 1041C0700X, 106H00000X, 101YM0800X
NCC0085211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty