Healthcare Provider Details

I. General information

NPI: 1053498683
Provider Name (Legal Business Name): HEALING HEARTS THERAPEUTIC SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 GUM BRANCH RD STE E
JACKSONVILLE NC
28540-6269
US

IV. Provider business mailing address

824 GUM BRANCH RD STE E
JACKSONVILLE NC
28540-6269
US

V. Phone/Fax

Practice location:
  • Phone: 910-347-1694
  • Fax: 910-347-3691
Mailing address:
  • Phone: 910-347-1694
  • Fax: 910-347-3691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEMETRIOUS SHEPARD
Title or Position: CEO CLINICAL DIRECTOR
Credential: LPC
Phone: 910-347-1694