Provider Demographics
NPI:1790358364
Name:QUEEN CITY BEHAVIORAL HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:QUEEN CITY BEHAVIORAL HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:980-236-8408
Mailing Address - Street 1:3623 LATROBE DR STE 124
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1172
Mailing Address - Country:US
Mailing Address - Phone:980-236-8408
Mailing Address - Fax:
Practice Address - Street 1:3623 LATROBE DR STE 124
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1172
Practice Address - Country:US
Practice Address - Phone:980-236-8408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health