Basic Information
| Provider Information | |||||||||
| NPI: | 1558887570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMBERS | ||||||||
| FirstName: | TERRITA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12436 BENDING BRANCH RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282273659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043450613 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5200 PARK RD STE 218B | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667001606 | ||||||||
| FaxNumber: | 8663385921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 12842 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0 | 01 | NONE | OTHER |