Provider Demographics
NPI:1760616296
Name:CENTER FOR SELF GROWTH PLLC
Entity Type:Organization
Organization Name:CENTER FOR SELF GROWTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:704-607-3324
Mailing Address - Street 1:144 W MOUNTAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-3446
Mailing Address - Country:US
Mailing Address - Phone:704-607-3324
Mailing Address - Fax:704-675-5814
Practice Address - Street 1:144 W MOUNTAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3446
Practice Address - Country:US
Practice Address - Phone:704-607-3324
Practice Address - Fax:704-675-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC003021251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health