=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245589076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE MATTERS CENTERS FOR HOPE, HEALTH AND HEALING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2012
-----------------------------------------------------
Last Update Date | 09/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 WADDELL DRIVE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-483-7068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 9532
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-483-7068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. PEARLIE MAE HODGES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 910-483-7068
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6216
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------