Healthcare Provider Details

I. General information

NPI: 1306141718
Provider Name (Legal Business Name): MIND OF HOPE COMMUNITY LIVING PROGRAM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7190 NC HIGHWAY 11
WILLARD NC
28478-7062
US

IV. Provider business mailing address

PO BOX 211
WILLARD NC
28478-0211
US

V. Phone/Fax

Practice location:
  • Phone: 910-441-7080
  • Fax: 910-552-5006
Mailing address:
  • Phone: 910-441-7080
  • Fax: 910-552-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2926
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2926
License Number StateNC

VIII. Authorized Official

Name: DR. MELVIN R THOMAS
Title or Position: PRESIDENT & CEO
Credential: PHD
Phone: 910-441-7080