Healthcare Provider Details

I. General information

NPI: 1568658516
Provider Name (Legal Business Name): ABUNDANT HEALTH AND HUMAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2007
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S GRIFFIN ST SUITE 175
ELIZABETH CITY NC
27909
US

IV. Provider business mailing address

P.O. BOX 2751
ELIZABETH CITY NC
27906-2751
US

V. Phone/Fax

Practice location:
  • Phone: 252-335-9400
  • Fax: 252-335-9404
Mailing address:
  • Phone: 252-335-9400
  • Fax: 252-335-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200001510
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-070-051
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TONYA JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential: BACHELORS/QUALIFIED
Phone: 252-335-9400