=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902151194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELS DREAM FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2012
-----------------------------------------------------
Last Update Date | 07/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 CAMDEN RD SUITE 106
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28203-4690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-499-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 CAMDEN RD SUITE 106
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28203-4690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-499-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. DULCE DELGADO CUSTODIO
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 401-499-6558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------