=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255658050
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUND MIND MINISTRIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2010
-----------------------------------------------------
Last Update Date | 05/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 W 2ND ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27292-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-470-3618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 W 2ND ST SOUND MIND MINISTRIES, LLC
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27292-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-470-3618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY BETH YOUNG
-----------------------------------------------------
Credential | MSW LCSW
-----------------------------------------------------
Telephone | 336-470-3618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C002788
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------