Healthcare Provider Details

I. General information

NPI: 1518074293
Provider Name (Legal Business Name): M & M OF THE CAROLINAS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 BEECHWOOD FARM RD
STATESVILLE NC
28625-9409
US

IV. Provider business mailing address

PO BOX 6254
GASTONIA NC
28056-6023
US

V. Phone/Fax

Practice location:
  • Phone: 704-832-3760
  • Fax: 704-500-2043
Mailing address:
  • Phone: 704-832-3760
  • Fax: 704-500-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number1332
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1195
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS CONSTANCE MICHELLE MONTGOMERY
Title or Position: CEO
Credential: BA, MPA, QP
Phone: 704-832-3760