Provider Demographics
NPI:1295768943
Name:PSYCHOLOGICAL SERVICES OF CHARLOTTE
Entity type:Organization
Organization Name:PSYCHOLOGICAL SERVICES OF CHARLOTTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:MONTELEONE
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:704-503-3535
Mailing Address - Street 1:1923 J N PEASE PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4513
Mailing Address - Country:US
Mailing Address - Phone:704-503-3535
Mailing Address - Fax:704-593-5555
Practice Address - Street 1:1923 J N PEASE PL
Practice Address - Street 2:SUITE 204
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4513
Practice Address - Country:US
Practice Address - Phone:704-503-3535
Practice Address - Fax:704-593-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0045441041C0700X
NC3953103T00000X
NC3660103T00000X
NC4444103T00000X
NC3328NCLPC101YP2500X
363LP0808X
NC12226101YP2500X
NC2846103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017TAOtherBCBS
NC7496772OtherAETNA
NC2331726AMedicare PIN
NC7496772OtherAETNA