Healthcare Provider Details

I. General information

NPI: 1275946741
Provider Name (Legal Business Name): CROSSROADS THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 VILLAGE DR SUITE 18-4
JACKSONVILLE NC
28546-7067
US

IV. Provider business mailing address

99 VILLAGE DR SUITE 18-4
JACKSONVILLE NC
28546-7067
US

V. Phone/Fax

Practice location:
  • Phone: 910-939-5144
  • Fax: 910-939-5934
Mailing address:
  • Phone: 910-939-5144
  • Fax: 910-939-5934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEJUAN JOYCE LUNDY
Title or Position: MEMBER/ORGANIZER
Credential: LPC, LCAS-A
Phone: 919-225-9315