Healthcare Provider Details

I. General information

NPI: 1336333558
Provider Name (Legal Business Name): PRO KIDS YOUTH AND FAMILY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2559 QUAIL RIDGE DR
GASTONIA NC
28056-9205
US

IV. Provider business mailing address

2559 QUAIL RIDGE DR
GASTONIA NC
28056-9205
US

V. Phone/Fax

Practice location:
  • Phone: 704-674-5455
  • Fax:
Mailing address:
  • Phone: 704-674-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. DEMISE LAMAAR WILLIAMS
Title or Position: CEO
Credential:
Phone: 704-674-5455