Healthcare Provider Details

I. General information

NPI: 1932723301
Provider Name (Legal Business Name): OPEN HEARTS HEALING MINDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 N POINT BLVD STE 139
WINSTON SALEM NC
27106-3262
US

IV. Provider business mailing address

611 RIVERSIDE DR
MOUNT AIRY NC
27030-3116
US

V. Phone/Fax

Practice location:
  • Phone: 336-546-5003
  • Fax:
Mailing address:
  • Phone: 336-401-3464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TABATHA COX
Title or Position: OWNER
Credential:
Phone: 336-546-5003