Healthcare Provider Details

I. General information

NPI: 1922863513
Provider Name (Legal Business Name): INNER SHALOM, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 MEADOW CREEK CHURCH RD
LOCUST NC
28097-8525
US

IV. Provider business mailing address

1230 MEADOW CREEK CHURCH RD
LOCUST NC
28097-8525
US

V. Phone/Fax

Practice location:
  • Phone: 252-325-4131
  • Fax:
Mailing address:
  • Phone: 252-325-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA MATA
Title or Position: OWNER, SOLE MEMBER/MANAGER
Credential: LCMHCA
Phone: 252-325-4131