=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972954113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELF DETERMINATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2016
-----------------------------------------------------
Last Update Date | 12/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 423 MILLSAP RD
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-600-6092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 423 MILLSAP RD
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150-9634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-600-6092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ANNE JEFFRIES
-----------------------------------------------------
Credential | BC-HSP
-----------------------------------------------------
Telephone | 980-297-8964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 623-203
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------