Healthcare Provider Details

I. General information

NPI: 1639408248
Provider Name (Legal Business Name): SELF-DETERMINATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 EBENEZER RD
KINGS MTN NC
28086
US

IV. Provider business mailing address

103 EBENEZER RD
KINGS MTN NC
28086-8762
US

V. Phone/Fax

Practice location:
  • Phone: 704-750-4752
  • Fax: 704-750-4753
Mailing address:
  • Phone: 704-750-4752
  • Fax: 704-750-4753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number023-197
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number012-129
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: FLOYDCE JEFFERIES
Title or Position: PRESIDENT
Credential:
Phone: 828-433-0465