=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720124829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW DIRECTIONS IN COMMUNITY SUPPORT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 01/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1931 J N PEASE PL STE 202
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-717-2800
-----------------------------------------------------
Fax | 704-717-6200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1931 J N PEASE PL STE 202
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-717-2800
-----------------------------------------------------
Fax | 704-717-6200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | ANGELA M HARGROW
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 704-717-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 2409
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C005010
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 2409
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 2409
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------