=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386159929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONUMENTAL FOUNDATIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2017
-----------------------------------------------------
Last Update Date | 08/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 N KERR AVE STE C2
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28405-3439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-540-6749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3953B MARKET ST
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-540-6749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JULIE SIMMONS
-----------------------------------------------------
Credential | LCMHC,LCAS,CCS
-----------------------------------------------------
Telephone | 910-540-6749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------