Provider Demographics
NPI:1356489363
Name:CHILDRENS ADVOCACY NETWORK LLC
Entity Type:Organization
Organization Name:CHILDRENS ADVOCACY NETWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT COORD
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDUFFIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-833-0154
Mailing Address - Street 1:1371 E GARRISON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5155
Mailing Address - Country:US
Mailing Address - Phone:704-833-0154
Mailing Address - Fax:704-833-7076
Practice Address - Street 1:526 RUBY LN
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4930
Practice Address - Country:US
Practice Address - Phone:704-868-5805
Practice Address - Fax:704-833-7076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X
NCMHL-036-285320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604440Medicaid
NC8300013BMedicaid