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General NPI Number Information
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NPI Number | 1518184027
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Entity Type | Organization
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Legal Business Name | COMMUNITY INTERVENTION CENTER, INC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/23/2007
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Provider Practice Location Address
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Address Line | 605 LYNNDALE CT STE A
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City | GREENVILLE
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State | NC
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Zip | 27858-5449
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Country | US
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Telephone | 252-321-7710
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Fax | 252-317-0516
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Provider Business Mailing Address
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Address Line | PO BOX 30196
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City | GREENVILLE
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State | NC
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Zip | 27833-0196
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Country | US
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Telephone | 252-321-7710
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Fax | 252-317-0516
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Authorized Official
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Title or Position | CEO PRESIDENT
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Name | MRS. VICKIE GORHAM PHILLIPS
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Credential |
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Telephone | 252-321-7710
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | NC
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