Provider Demographics
NPI:1306062856
Name:CHEMICAL DEPENDENCY SERVICES, INC
Entity type:Organization
Organization Name:CHEMICAL DEPENDENCY SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LYNDON
Authorized Official - Last Name:BECK
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:704-289-4877
Mailing Address - Street 1:308 W. WINDSOR STREET
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-4779
Mailing Address - Country:US
Mailing Address - Phone:704-289-4887
Mailing Address - Fax:704-289-5188
Practice Address - Street 1:308 W. WINDSOR STREET
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4779
Practice Address - Country:US
Practice Address - Phone:704-289-4887
Practice Address - Fax:704-289-5188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-090-058261QM0801X
NCMHL-090-162261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-090-058OtherLICENSE NUMBER
NC050089OtherFACILITY ID
NC50315OtherDWI PROVIDER