Healthcare Provider Details

I. General information

NPI: 1922277417
Provider Name (Legal Business Name): ABC OF NC CHILD DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 FRIEDBERG CHURCH RD
WINSTON SALEM NC
27127-9803
US

IV. Provider business mailing address

905 FRIEDBERG CHURCH RD
WINSTON SALEM NC
27127-9803
US

V. Phone/Fax

Practice location:
  • Phone: 336-251-1180
  • Fax: 336-251-1181
Mailing address:
  • Phone: 336-251-1180
  • Fax: 336-251-1181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1084186
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number122977
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0125034
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4074
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SELENE JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential: M.ED.
Phone: 336-251-1180