Healthcare Provider Details

I. General information

NPI: 1124218243
Provider Name (Legal Business Name): MY SISTER'S PLACE COMMUNITY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 S MAIN ST
WINSTON SALEM NC
27127-4006
US

IV. Provider business mailing address

908 GLENCOE ST
WINSTON SALEM NC
27107-3315
US

V. Phone/Fax

Practice location:
  • Phone: 336-784-5922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: JOAN MARIE WHITE
Title or Position: CEO & EXECUTIVE DIRECTOR
Credential:
Phone: 336-784-5922