Provider Demographics
NPI:1487819363
Name:SHADOWS COMMUNITY SUPPORT CENTER LLC
Entity Type:Organization
Organization Name:SHADOWS COMMUNITY SUPPORT CENTER LLC
Other - Org Name:GLORIA CRANDELL-NELSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDELL-NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-795-6662
Mailing Address - Street 1:7356 HWY 64 E ALT
Mailing Address - Street 2:
Mailing Address - City:ROBERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27871
Mailing Address - Country:US
Mailing Address - Phone:252-795-6662
Mailing Address - Fax:
Practice Address - Street 1:7356 HWY 64 E ALT
Practice Address - Street 2:
Practice Address - City:ROBERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27871
Practice Address - Country:US
Practice Address - Phone:252-795-6662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0042301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003087Medicaid
NC5950083Medicaid