Organization
FUTURE IMPRESSION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BERTINA BROADNAX (CEO)
(980) 365-9879
Entity
Organization
Contact information
Practice address
619 SULLIVAN STREET, CHARLOTTE, NC 28214
(980) 365-9879
Mailing address
P.O. BOX 16695, CHARLOTTE, NC 28297
(980) 365-9879
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
101YM0800X
Mental Health Counselor
—
—
171M00000X
Case Manager/Care Coordinator
—
—
175T00000X
Peer Specialist
—
—
Other
Enumeration date
04/09/2018
Last updated
04/09/2018
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