Provider Demographics
NPI:1922766849
Name:PROTEA PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:PROTEA PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:704-668-6635
Mailing Address - Street 1:1923 J N PEASE PL STE 104
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4534
Mailing Address - Country:US
Mailing Address - Phone:704-859-2762
Mailing Address - Fax:541-314-9554
Practice Address - Street 1:1923 J N PEASE PL STE 104
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4534
Practice Address - Country:US
Practice Address - Phone:704-668-6635
Practice Address - Fax:541-314-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health