Healthcare Provider Details

I. General information

NPI: 1962932822
Provider Name (Legal Business Name): MINDGATE BEHAVIORAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 TAYLOR AVE
HIGH POINT NC
27260-7369
US

IV. Provider business mailing address

803 TAYLOR AVE
HIGH POINT NC
27260-7369
US

V. Phone/Fax

Practice location:
  • Phone: 336-689-3444
  • Fax: 336-886-1421
Mailing address:
  • Phone: 336-689-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20131
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License NumberS8977
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. SYLVESTER R SMITH
Title or Position: OWNER
Credential: MSRC, LCMHCS, LCAS
Phone: 336-689-3444