1861874794 NPI number — 321 MENTAL HEALTH/SUBSTANCE ABUSE CRISIS RESPONSE CENTER, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861874794 NPI number — 321 MENTAL HEALTH/SUBSTANCE ABUSE CRISIS RESPONSE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
321 MENTAL HEALTH/SUBSTANCE ABUSE CRISIS RESPONSE CENTER, PLLC
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:
1861874794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 562
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTHEWS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28106-0562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-918-8513
Provider Business Mailing Address Fax Number:
704-291-9354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3232 SUMMERFIELD RIDGE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-8507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-918-8513
Provider Business Practice Location Address Fax Number:
704-291-9354
Provider Enumeration Date:
06/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HUBBARD
Authorized Official First Name:
REGENIA
Authorized Official Middle Name:
MAE
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
919-247-0535

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  C009113 , 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)





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