1750414132 NPI number — MECKLENBURG OPEN DOOR, INC.

Table of content: MS. HEATHER CHRISTINE SHIRM MSW, LCSW (NPI 1447881388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750414132 NPI number — MECKLENBURG OPEN DOOR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MECKLENBURG OPEN DOOR, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750414132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 MOCKINGBIRD LN
Provider Second Line Business Mailing Address:
SUITE 1015
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28209-3236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-525-3255
Provider Business Mailing Address Fax Number:
704-525-0949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3711 CARMEL FOREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28226-8117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-542-8727
Provider Business Practice Location Address Fax Number:
704-542-9198
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAYTON
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
G
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
704-525-3255

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  MHL-060-248 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7802714 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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