KINGSPOINTE BEHAVIORAL HEALTHCARE SERVICES, LLC

Provider Demographics

• NPI: 1477692242
• Name: KINGSPOINTE BEHAVIORAL HEALTHCARE SERVICES, LLC
• Entity Type: Organization
• Organization Name: KINGSPOINTE BEHAVIORAL HEALTHCARE SERVICES, LLC
• Other - Org Name: KINGSPOINTE ACADEMY, LLC
• Other - Org Type: Former Legal Business Name
• Authorized Official - Title/Position: EXECUTIVEDIRECTORCLINICALSERVICES
• Authorized Official - Prefix: MR
• Authorized Official - First Name: LLRAE
• Authorized Official - Last Name: SCOTT
• Authorized Official - Credentials: BS, QMHP
• Authorized Official - Phone: 704-487-6226
• Mailing Address - Street 1: 201 W MARION ST
• Mailing Address - Street 2: SUITE 207
• Mailing Address - City: SHELBY
• Mailing Address - State: NC
• Mailing Address - Zip Code: 28150-5091
• Mailing Address - Country: US
• Mailing Address - Phone: 704-487-6226
• Mailing Address - Fax: 704-487-6286
• Practice Address - Street 1: 201 W MARION ST
• Practice Address - Street 2: SUITE 207
• Practice Address - City: SHELBY
• Practice Address - State: NC
• Practice Address - Zip Code: 28150-5091
• Practice Address - Country: US
• Practice Address - Phone: 704-487-6226
• Practice Address - Fax: 704-487-6286
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-02-06
• Last Update Date: 2008-01-09

Provider Licenses

State	License ID	Taxonomies
NC	2260	101YM0800X
NC	5595	101YM0800X
		251C00000X, 251S00000X
NC	MHL-023-046	322D00000X
NC	MHL-023-128	322D00000X
NC	MHL-055-090	322D00000X
NC	MHL-055-091	322D00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	251S00000X	Agencies	Community/Behavioral Health
No	101YM0800X	Behavioral Health & Social Service Providers	Counselor	Mental Health	Group - Multi-Specialty
No	251C00000X	Agencies	Day Training, Developmentally Disabled Services		Group - Multi-Specialty
No	322D00000X	Residential Treatment Facilities	Residential Treatment Facility, Emotionally Disturbed Children

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	3418018	Medicaid
NC	6603802	Medicaid
NC	8300864	Medicaid
NC	8300864G	Medicaid
NC	6604075	Medicaid
NC	6603801	Medicaid
NC	8300864B	Medicaid
NC	6005943	Medicaid
NC	6604071	Medicaid
NC	8300864H	Medicaid