Provider Demographics
NPI:1386196897
Name:HOME FOR FAMILY INTIMACY, PLLC
Entity type:Organization
Organization Name:HOME FOR FAMILY INTIMACY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:980-224-0653
Mailing Address - Street 1:10130 MALLARD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-6000
Mailing Address - Country:US
Mailing Address - Phone:980-224-0653
Mailing Address - Fax:980-729-5025
Practice Address - Street 1:10130 MALLARD CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6000
Practice Address - Country:US
Practice Address - Phone:980-224-0653
Practice Address - Fax:980-729-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0102281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty