Healthcare Provider Details

I. General information

NPI: 1316560345
Provider Name (Legal Business Name): MELIORA THERAPY AND CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LANARK TRL
SOUTHERN PINES NC
28387-7513
US

IV. Provider business mailing address

216 COMMERCE AVE # 189
SOUTHERN PINES NC
28387-7059
US

V. Phone/Fax

Practice location:
  • Phone: 719-270-1722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOMINIQUE ALINA DIJKHUIZEN
Title or Position: SOCIAL WORKER
Credential: LCSW
Phone: 850-502-0671