Healthcare Provider Details

I. General information

NPI: 1023316361
Provider Name (Legal Business Name): CHILDREN'S ADVOCACY NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 E GARRISON BLVD STE A
GASTONIA NC
28054
US

IV. Provider business mailing address

1371 E GARRISON BLVD STE A
GASTONIA NC
28054-5155
US

V. Phone/Fax

Practice location:
  • Phone: 704-833-0154
  • Fax: 704-833-7076
Mailing address:
  • Phone: 704-833-0154
  • Fax: 704-833-7076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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 TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY O BEAUDOIN
Title or Position: CO-OWNER
Credential: MA
Phone: 704-833-0154