=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740069905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED CARE SUSTAINS NETWORKS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2023
-----------------------------------------------------
Last Update Date | 09/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3675 FALLSTAFF DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28306-9079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-699-2633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1298 5075 MORGATON RD STE 10C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-699-2633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. QUADIEDRA AMOS
-----------------------------------------------------
Credential | LCMHC
-----------------------------------------------------
Telephone | 910-699-2633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------