Healthcare Provider Details

I. General information

NPI: 1235829722
Provider Name (Legal Business Name): KAM'S CORNER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E BLUE RIDGE STREET
STUART VA
24171
US

IV. Provider business mailing address

1612 FAIRCREST LN
GREENSBORO NC
27406-9809
US

V. Phone/Fax

Practice location:
  • Phone: 276-734-3421
  • Fax:
Mailing address:
  • Phone: 276-734-3421
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TINA NICOLE STREET
Title or Position: CEO
Credential: MSW/LCSW
Phone: 276-734-3421