Healthcare Provider Details

I. General information

NPI: 1902124191
Provider Name (Legal Business Name): COMMUNITY CONNECTIONS HEALTHCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 N REILLY RD
FAYETTEVILLE NC
28303-5724
US

IV. Provider business mailing address

282 W MILLBROOK RD SUITE 100
RALEIGH NC
27609-4676
US

V. Phone/Fax

Practice location:
  • Phone: 910-879-6102
  • Fax: 919-544-1661
Mailing address:
  • Phone: 919-665-4673
  • Fax: 919-544-1661

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number127550
License Number StateNC

VIII. Authorized Official

Name: MS. ALLESHA MCKOY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 910-879-6102