=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174848246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAKING A DIFFERENCE COMMUNITY SUPPORT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2010
-----------------------------------------------------
Last Update Date | 04/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 W WATER ST
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27962-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-793-2823
-----------------------------------------------------
Fax | 252-793-4139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 MACKEYS RD
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27962-9609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DESIGNEE
-----------------------------------------------------
Name | ORLANDO SMALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-931-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------