Healthcare Provider Details

I. General information

NPI: 1851002794
Provider Name (Legal Business Name): SNAPBACK NC, CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N BROAD ST
EDENTON NC
27932-1430
US

IV. Provider business mailing address

703 N BROAD ST
EDENTON NC
27932-1430
US

V. Phone/Fax

Practice location:
  • Phone: 252-698-1389
  • Fax:
Mailing address:
  • Phone: 252-698-1389
  • Fax: 252-368-1529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: MS. COURTNEY LAYNE BUTLER
Title or Position: PRESIDENT
Credential: NCCPSS
Phone: 252-260-9406