Healthcare Provider Details

I. General information

NPI: 1548673759
Provider Name (Legal Business Name): MISSION MEDICAL ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 RANKIN DR SUITE 10
MARION NC
28752-6568
US

IV. Provider business mailing address

PO BOX 602373
CHARLOTTE NC
28260-2373
US

V. Phone/Fax

Practice location:
  • Phone: 828-213-4502
  • Fax: 828-213-4540
Mailing address:
  • Phone: 828-651-6415
  • Fax: 828-651-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JILL HOGGARD GREEN
Title or Position: PRESIDENT
Credential: PHD
Phone: 828-213-9637