Provider Demographics
NPI:1336333129
Name:612 BEHAVIORAL AND COMMUNITY SERVICES
Entity type:Organization
Organization Name:612 BEHAVIORAL AND COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEMISE
Authorized Official - Middle Name:LAMAAR
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-674-5455
Mailing Address - Street 1:2559 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-9205
Mailing Address - Country:US
Mailing Address - Phone:704-674-5455
Mailing Address - Fax:
Practice Address - Street 1:2559 QUAIL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-9205
Practice Address - Country:US
Practice Address - Phone:704-674-5455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health