Healthcare Provider Details

I. General information

NPI: 1376997791
Provider Name (Legal Business Name): THE PROMISE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 PARK PL APT 347P
HATTIESBURG MS
39402-1570
US

IV. Provider business mailing address

8 PARK PL APT 347P
HATTIESBURG MS
39402-1570
US

V. Phone/Fax

Practice location:
  • Phone: 704-277-5227
  • Fax:
Mailing address:
  • Phone: 704-277-5227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. KIMBERLY BUNCH-CRUMP
Title or Position: DIRECTOR
Credential: BCBA
Phone: 704-277-5227