=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003069188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACCESS THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2008
-----------------------------------------------------
Last Update Date | 11/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 ARROWOOD AVE
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29720-1503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-813-4555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3140 HWY 16 N. SUITE 103
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28036-7314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-813-4555
-----------------------------------------------------
Fax | 704-296-5500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. ANNIE FONGHEISER
-----------------------------------------------------
Credential | MA, MS, MAC, LCAS
-----------------------------------------------------
Telephone | 704-813-4555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 945
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------