Healthcare Provider Details

I. General information

NPI: 1912186735
Provider Name (Legal Business Name): MAKING A DIFFERENCE COMMUNITY SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 OLD TOM AVE.
MANTEO NC
27954
US

IV. Provider business mailing address

PO BOX 7672
KILL DEVIL HILLS NC
27948-6672
US

V. Phone/Fax

Practice location:
  • Phone: 252-475-9829
  • Fax:
Mailing address:
  • Phone: 252-475-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number261QM0850X
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number261QM0855X
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number261QR0400X
License Number StateNC

VIII. Authorized Official

Name: SHANEQUA CORNISE BENTON
Title or Position: MEMBER/ORGANIZER
Credential:
Phone: 252-475-9829