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General NPI Number Information
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NPI Number | 1528232915
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Entity Type | Organization
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Legal Business Name | PINE VILLAGE TREATMENT SERVICES, INC.
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Dates
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Enumeration Date | 04/16/2008
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Last Update Date | 10/01/2008
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Provider Practice Location Address
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Address Line | 1206 HOPE MILLS RD
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City | FAYETTEVILLE
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State | NC
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Zip | 28304-4215
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Country | US
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Telephone | 910-864-7004
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Fax | 910-864-3002
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Provider Business Mailing Address
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Address Line | 1206 HOPE MILLS RD
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City | FAYETTEVILLE
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State | NC
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Zip | 28304-4215
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Country | US
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Telephone | 910-864-7004
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Fax | 910-864-3002
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHRIS A DEREPENTIGNY
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Credential |
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Telephone | 910-864-7004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MHL-047-096
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License Number State | NC
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