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General NPI Number Information
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NPI Number | 1689934077
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Entity Type | Organization
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Legal Business Name | SUPREME TEENS, L&C
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Dates
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Enumeration Date | 05/21/2012
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Last Update Date | 05/21/2012
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Provider Practice Location Address
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Address Line | 14495 HWY 301 N.
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City | ENFIELD
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State | NC
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Zip | 27823
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Country | US
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Telephone | 252-467-3407
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Fax | 252-445-1073
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Provider Business Mailing Address
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Address Line | 14495 HWY 301 N.
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City | ENFIELD
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State | NC
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Zip | 27823
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Country | US
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Telephone | 252-467-3407
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Fax | 252-445-1073
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Authorized Official
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Title or Position | DIRECTOR/COORDINATOR
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Name | TREVATHAN MARQUETTE EL
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Credential |
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Telephone | 252-467-3407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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