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General NPI Number Information
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NPI Number | 1154475572
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Entity Type | Organization
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Legal Business Name | IMPACT COMMUNITY SUPPORT SERVICES, INC.
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 10130 MALLARD CREEK RD SUITE 300
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City | CHARLOTTE
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State | NC
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Zip | 28262-6000
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Country | US
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Telephone | 704-506-6204
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Fax |
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Provider Business Mailing Address
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Address Line | 2183 MALLARD POINTE DR
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City | KANNAPOLIS
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State | NC
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Zip | 28083-6204
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Country | US
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Telephone | 704-506-6204
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. SHAWNTAL ISAIAH
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Credential | LCSW
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Telephone | 704-506-6204
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C005180
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License Number State | NC
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