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Organization

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Active
Organization subpart
No

Provider details

NPI number
Authorized official
MS. LATASHA SHAWNTAY MCILWAINE MA, MHA, LPC, LCAS (OWNER/ THERAPIST)
(704) 340-4666
Entity
Organization

Contact information

Practice address
1409 EAST BLVD, SUITE 6B, CHARLOTTE, NC 28203-5817
(704) 340-4666
Mailing address
PO BOX 743, PAW CREEK, NC 28130-0743
(704) 340-4666

Taxonomy

Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
6691
NC
251S00000X
Community/Behavioral Health Agency
1296
NC

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
6006425
NC
05
6103719
NC
Enumeration date
05/09/2008
Last updated
03/28/2009
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