Provider Demographics
NPI:1154475572
Name:IMPACT COMMUNITY SUPPORT SERVICES, INC.
Entity Type:Organization
Organization Name:IMPACT COMMUNITY SUPPORT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWNTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISAIAH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:704-506-6204
Mailing Address - Street 1:2183 MALLARD POINTE DR
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6204
Mailing Address - Country:US
Mailing Address - Phone:704-506-6204
Mailing Address - Fax:
Practice Address - Street 1:10130 MALLARD CREEK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6000
Practice Address - Country:US
Practice Address - Phone:704-506-6204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0051801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty