Provider Demographics
NPI:1588161350
Name:FUTURE IMPRESSION
Entity type:Organization
Organization Name:FUTURE IMPRESSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BERTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADNAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-365-9879
Mailing Address - Street 1:P.O. BOX 16695
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28297
Mailing Address - Country:US
Mailing Address - Phone:980-365-9879
Mailing Address - Fax:
Practice Address - Street 1:619 SULLIVAN STREET
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214
Practice Address - Country:US
Practice Address - Phone:980-365-9879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty