Healthcare Provider Details

I. General information

NPI: 1821140401
Provider Name (Legal Business Name): NEW LEAF ADOLESCENT CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 J N PEASE PL STE 102
CHARLOTTE NC
28262-4555
US

IV. Provider business mailing address

1945 J N PEASE PL STE 102
CHARLOTTE NC
28262-4555
US

V. Phone/Fax

Practice location:
  • Phone: 704-405-8890
  • Fax: 704-405-8893
Mailing address:
  • Phone: 704-405-8890
  • Fax: 704-405-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number8301256B
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-060-802
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-090-146
License Number StateNC

VIII. Authorized Official

Name: MR. MICKEY LEON RIVERS SR.
Title or Position: CEO
Credential:
Phone: 704-891-5825