Provider Demographics
NPI:1376620138
Name:THE MENTOR NETWORK
Entity Type:Organization
Organization Name:THE MENTOR NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVAULT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEVENGER
Authorized Official - Suffix:
Authorized Official - Credentials:MA LCSW
Authorized Official - Phone:910-673-3535
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:BISCOE
Mailing Address - State:NC
Mailing Address - Zip Code:27209-0310
Mailing Address - Country:US
Mailing Address - Phone:910-673-3535
Mailing Address - Fax:910-673-6565
Practice Address - Street 1:241 GRANT STREET
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376
Practice Address - Country:US
Practice Address - Phone:910-673-3535
Practice Address - Fax:901-673-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005890Medicaid