Healthcare Provider Details

I. General information

NPI: 1992833271
Provider Name (Legal Business Name): ST. MICHAEL'S THERAPEUTIC SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 S ROWAN AVE
SPENCER NC
28159-2146
US

IV. Provider business mailing address

708 S ROWAN AVE
SPENCER NC
28159-2146
US

V. Phone/Fax

Practice location:
  • Phone: 704-637-3375
  • Fax: 704-637-3375
Mailing address:
  • Phone: 704-637-3375
  • Fax: 704-637-3375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-080-120
License Number StateNC

VIII. Authorized Official

Name: MS. TASHEEMA YVETTE SHORE
Title or Position: OWNER
Credential: BS.QP
Phone: 704-701-2582