Healthcare Provider Details

I. General information

NPI: 1720124829
Provider Name (Legal Business Name): NEW DIRECTIONS IN COMMUNITY SUPPORT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 J N PEASE PL STE 202
CHARLOTTE NC
28262-4543
US

IV. Provider business mailing address

1931 J N PEASE PL STE 202
CHARLOTTE NC
28262-4543
US

V. Phone/Fax

Practice location:
  • Phone: 704-717-2800
  • Fax: 704-717-6200
Mailing address:
  • Phone: 704-717-2800
  • Fax: 704-717-6200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2409
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005010
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number2409
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2409
License Number StateNC

VIII. Authorized Official

Name: ANGELA M HARGROW
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 704-717-2800