Provider Demographics
NPI:1396074159
Name:CHILD & FAMILY THERAPY CENTER PC
Entity type:Organization
Organization Name:CHILD & FAMILY THERAPY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:H
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-7148
Mailing Address - Street 1:363 WILLIAMSON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5974
Mailing Address - Country:US
Mailing Address - Phone:704-664-7148
Mailing Address - Fax:704-664-3086
Practice Address - Street 1:715 FAIRGROVE CHURCH RD SE
Practice Address - Street 2:SUITE 102
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-9290
Practice Address - Country:US
Practice Address - Phone:704-664-7148
Practice Address - Fax:704-664-3086
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILD & FAMILY THERAPY CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-08
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC851101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006780Medicaid