Healthcare Provider Details

I. General information

NPI: 1982042933
Provider Name (Legal Business Name): GHA AUTISM SUPPORTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N 2ND ST
ALBEMARLE NC
28001-3939
US

IV. Provider business mailing address

PO BOX 2487
ALBEMARLE NC
28002-2487
US

V. Phone/Fax

Practice location:
  • Phone: 704-982-9600
  • Fax: 704-982-8155
Mailing address:
  • Phone: 704-982-9600
  • Fax: 704-982-8155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: DAWN HARWOOD ALLEN
Title or Position: CEO
Credential:
Phone: 704-982-9600