Healthcare Provider Details

I. General information

NPI: 1265747927
Provider Name (Legal Business Name): MY GOAL OUR MISSION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 FOREST HILLS DR
GARNER NC
27529-3624
US

IV. Provider business mailing address

208 FOREST HILLS DR
GARNER NC
27529-3624
US

V. Phone/Fax

Practice location:
  • Phone: 919-800-0016
  • Fax:
Mailing address:
  • Phone: 919-800-0016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALLISON MARIE BRISTOW-CHISLEY
Title or Position: CEO
Credential:
Phone: 919-523-8651