Provider Demographics
NPI:1043527591
Name:FRESH START BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:FRESH START BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:BA, SA CERTIFIED
Authorized Official - Phone:336-473-7597
Mailing Address - Street 1:1001 S MARSHALL ST
Mailing Address - Street 2:SUITE 230 , 2-98 (BOX88)
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5852
Mailing Address - Country:US
Mailing Address - Phone:336-473-7597
Mailing Address - Fax:
Practice Address - Street 1:1001 S MARSHALL ST
Practice Address - Street 2:SUITE 230 2-98 BOX88
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5852
Practice Address - Country:US
Practice Address - Phone:336-473-7597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-04
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health