Provider Demographics
NPI:1205515566
Name:ASCENTIA MIND AND BODY WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:ASCENTIA MIND AND BODY WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEF EXECUTIVE OFFICER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:704-909-0304
Mailing Address - Street 1:1914 J N PEASE PL STE 180&182
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4504
Mailing Address - Country:US
Mailing Address - Phone:704-909-0302
Mailing Address - Fax:
Practice Address - Street 1:1914 J N PEASE PL STE 180&182
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4504
Practice Address - Country:US
Practice Address - Phone:704-909-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-14
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center