Healthcare Provider Details

I. General information

NPI: 1669805115
Provider Name (Legal Business Name): SOUTHMOUNTAIN CHILDREN AND FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 ROCK WALL LN
BURNSVILLE NC
28714-8567
US

IV. Provider business mailing address

7330 MYRTLE DR
NEBO NC
28761-8666
US

V. Phone/Fax

Practice location:
  • Phone: 828-675-1508
  • Fax:
Mailing address:
  • Phone: 828-584-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM CHRISTOPHER JERNIGAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 828-584-1105