Provider Demographics
NPI:1073702429
Name:ST. MICHAEL'S THERAPEUTIC SERVICES, INC. #2
Entity Type:Organization
Organization Name:ST. MICHAEL'S THERAPEUTIC SERVICES, INC. #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TASHEEMA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:BS,QP
Authorized Official - Phone:704-701-2582
Mailing Address - Street 1:4477 FAWNBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-0412
Mailing Address - Country:US
Mailing Address - Phone:704-637-3375
Mailing Address - Fax:704-782-9383
Practice Address - Street 1:4477 FAWNBROOK AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-0412
Practice Address - Country:US
Practice Address - Phone:704-637-3375
Practice Address - Fax:704-782-9383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-080-163322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children