Healthcare Provider Details

I. General information

NPI: 1578719860
Provider Name (Legal Business Name): FAMILY INTERVENTION & COMMUNITY ADVOCACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MCCULLOUGH DR 4TH FLOOR
CHARLOTTE NC
28262-3310
US

IV. Provider business mailing address

301 MCCULLOUGH DR 4TH FLOOR
CHARLOTTE NC
28262-3310
US

V. Phone/Fax

Practice location:
  • Phone: 919-623-4485
  • Fax: 252-793-3117
Mailing address:
  • Phone: 919-623-4485
  • Fax: 252-793-3117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SHEMEIKA ANNTOINETTE LEWIS
Title or Position: PRESIDENT
Credential: B.A.
Phone: 919-623-4485