Healthcare Provider Details

I. General information

NPI: 1326435314
Provider Name (Legal Business Name): CROWN LEGACY SUPPORTIVE SERVICESLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E 5TH ST SUITE 216
CHARLOTTE NC
28202-3001
US

IV. Provider business mailing address

715 E 5TH ST SUITE 216
CHARLOTTE NC
28202-3001
US

V. Phone/Fax

Practice location:
  • Phone: 704-333-5686
  • Fax: 704-376-1931
Mailing address:
  • Phone: 704-333-5686
  • Fax: 704-376-1931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SANDRA BRADLEY REID
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MHA,MBA
Phone: 704-333-5686