Healthcare Provider Details

I. General information

NPI: 1710619580
Provider Name (Legal Business Name): AFFECT PROVIDER GROUP, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 TRINDALE RD # A
ARCHDALE NC
27263-3800
US

IV. Provider business mailing address

116 N 3RD ST STE 3
DANVILLE KY
40422-1691
US

V. Phone/Fax

Practice location:
  • Phone: 845-769-8758
  • Fax: 888-398-1839
Mailing address:
  • Phone: 845-769-8785
  • Fax: 888-398-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KARLA RENEE MULLINGS
Title or Position: DIRECTOR OF COMPLIANCE
Credential:
Phone: 845-768-8758