Healthcare Provider Details

I. General information

NPI: 1104057488
Provider Name (Legal Business Name): GENERATIONS OF HOPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 LARKSPUR DR
FAYETTEVILLE NC
28311-6955
US

IV. Provider business mailing address

656 LARKSPUR DR
FAYETTEVILLE NC
28311-6955
US

V. Phone/Fax

Practice location:
  • Phone: 910-822-4071
  • Fax: 910-488-1122
Mailing address:
  • Phone: 910-822-4071
  • Fax: 910-488-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNC

VIII. Authorized Official

Name: MRS. BIANCA P GANTT
Title or Position: CONSULTANT
Credential: LCSW
Phone: 910-822-4071