Provider Demographics
NPI:1104453547
Name:MASK OFF THERAPEUTIC PLLC
Entity type:Organization
Organization Name:MASK OFF THERAPEUTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEBA
Authorized Official - Middle Name:SABAN
Authorized Official - Last Name:BOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW
Authorized Official - Phone:203-530-0245
Mailing Address - Street 1:5912 BRIGHTSTAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7691
Mailing Address - Country:US
Mailing Address - Phone:203-530-0245
Mailing Address - Fax:704-910-3057
Practice Address - Street 1:8501 TOWER POINT DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7849
Practice Address - Country:US
Practice Address - Phone:203-530-0245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1041C0700XMedicaid