Provider Demographics
NPI:1619644044
Name:EQUIPOISE COUNSELING ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:EQUIPOISE COUNSELING ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:309-706-9336
Mailing Address - Street 1:229 S BREVARD ST STE 200F
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2495
Mailing Address - Country:US
Mailing Address - Phone:704-490-3867
Mailing Address - Fax:
Practice Address - Street 1:229 S BREVARD ST STE 200F
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2495
Practice Address - Country:US
Practice Address - Phone:704-490-3867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)