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General NPI Number Information
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NPI Number | 1770924482
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Entity Type | Organization
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Legal Business Name | PELHAM SUPPORTIVE SERVICES
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Dates
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Enumeration Date | 07/10/2013
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Last Update Date | 07/11/2013
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Provider Practice Location Address
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Address Line | 5740 LONGVIEW DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28306-8567
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Country | US
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Telephone | 910-425-4168
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Fax | 910-488-8823
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Provider Business Mailing Address
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Address Line | 949 COUNTRY CLUB DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28301-2907
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Country | US
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Telephone | 910-488-7633
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MILDRED WILSON
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Credential |
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Telephone | 910-488-7633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | MHL-026-854
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License Number State | NC
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