Provider Demographics
NPI:1679114102
Name:KINTSUGI COUNSELING PROFESSIONAL LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:KINTSUGI COUNSELING PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA CRUZ SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-644-9613
Mailing Address - Street 1:1403 EASTCREST DR APT 202
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-8277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:322 LAMAR AVE STE 209
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2436
Practice Address - Country:US
Practice Address - Phone:704-644-9613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689191983OtherNPI FOR PRIVATE INSURANCE
1962854505OtherNPI FOR PRIVATE INSURANCE