Provider Demographics
NPI:1437652328
Name:AVALON COMMUNITY AND PERSONAL DEVELOPMENT
Entity Type:Organization
Organization Name:AVALON COMMUNITY AND PERSONAL DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEREK
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:757-272-3415
Mailing Address - Street 1:405 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27855-1342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 WILLIAMS STREET
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:NC
Practice Address - Zip Code:27855
Practice Address - Country:US
Practice Address - Phone:757-272-3415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)