Healthcare Provider Details

I. General information

NPI: 1942915509
Provider Name (Legal Business Name): CHANGING PATHS NC II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MARTHA LN
CLINTON NC
28328-9639
US

IV. Provider business mailing address

205 MARTHA LANE
CLINTON NC
28328-9639
US

V. Phone/Fax

Practice location:
  • Phone: 910-631-1036
  • Fax:
Mailing address:
  • Phone: 175-789-7568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SUZAN TEAGUE
Title or Position: OWNER
Credential:
Phone: 910-631-1036