Provider Demographics
NPI:1306224019
Name:ADVANCE INTERGRATED MENTORING
Entity Type:Organization
Organization Name:ADVANCE INTERGRATED MENTORING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SORDAO
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS-A
Authorized Official - Phone:336-404-2110
Mailing Address - Street 1:205 S SKIPPER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28379-3843
Mailing Address - Country:US
Mailing Address - Phone:336-404-2110
Mailing Address - Fax:
Practice Address - Street 1:205 S SKIPPER ST
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-3843
Practice Address - Country:US
Practice Address - Phone:336-404-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2827-A252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency