Provider Demographics
NPI:1043692809
Name:MERIDIAN SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:MERIDIAN SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-289-4084
Mailing Address - Street 1:1880 CONCORD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-3060
Mailing Address - Country:US
Mailing Address - Phone:910-207-6421
Mailing Address - Fax:
Practice Address - Street 1:1880 CONCORD AVE STE C
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3060
Practice Address - Country:US
Practice Address - Phone:910-207-6421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
NCA11668101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1043692809Medicaid