Healthcare Provider Details

I. General information

NPI: 1619659026
Provider Name (Legal Business Name): FOOTHILLS BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 N CAROLINA AVE
BOONVILLE NC
27011-8934
US

IV. Provider business mailing address

122 N CAROLINA AVE
BOONVILLE NC
27011-8934
US

V. Phone/Fax

Practice location:
  • Phone: 336-303-0585
  • Fax:
Mailing address:
  • Phone: 336-303-0585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LARRY DALE SMITH
Title or Position: CLINICAL DIRECTOR
Credential: LCMHC
Phone: 336-303-0585