Healthcare Provider Details

I. General information

NPI: 1851461552
Provider Name (Legal Business Name): COMMUNITY INNOVATIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 GODWIN AVE SUITE A
LUMBERTON NC
28358-3197
US

IV. Provider business mailing address

2003 GODWIN AVE SUITE A
LUMBERTON NC
28358-3197
US

V. Phone/Fax

Practice location:
  • Phone: 910-739-8849
  • Fax: 919-739-8698
Mailing address:
  • Phone: 910-739-8849
  • Fax: 919-739-8698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: ANDY ANDERSON
Title or Position: CEO PRESIDENT
Credential:
Phone: 910-739-8849