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General NPI Number Information
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NPI Number | 1639561194
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Entity Type | Organization
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Legal Business Name | SUCCESSFUL MINDS, LLC
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Dates
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Enumeration Date | 02/20/2015
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Last Update Date | 02/20/2015
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Provider Practice Location Address
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Address Line | 2134 CAPERNIUM RD TR#2
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City | CHERRYVILLE
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State | NC
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Zip | 28021-9478
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Country | US
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Telephone | 704-769-4075
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Fax | 704-769-4136
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Provider Business Mailing Address
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Address Line | 2134 CAPERNIUM RD TR#2
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City | CHERRYVILLE
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State | NC
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Zip | 28021-9478
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Country | US
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Telephone | 704-769-4075
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Fax | 704-769-4136
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Authorized Official
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Title or Position | PARTNER OWNER
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Name | MRS. ANNETTE WILLIAM BURSTON
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Credential | BS, M.ED
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Telephone | 704-431-8100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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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 | 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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