Healthcare Provider Details

I. General information

NPI: 1346315595
Provider Name (Legal Business Name): FRIDAY'S PLACE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S OAKLAND ST STE A
GASTONIA NC
28054-0472
US

IV. Provider business mailing address

PO BOX 2212
GASTONIA NC
28053-2212
US

V. Phone/Fax

Practice location:
  • Phone: 704-864-0366
  • Fax: 704-864-0311
Mailing address:
  • Phone: 704-864-0366
  • Fax: 704-864-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5909113
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number8300372
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number3408063
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6005964
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number3408063
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number8300372
License Number StateNC

VIII. Authorized Official

Name: MR. KENNETH L FRIDAY
Title or Position: EXECUTIVE DIRECTOR
Credential: QMHP
Phone: 704-864-0366