Provider Demographics
NPI:1518074293
Name:M & M OF THE CAROLINAS, INC.
Entity Type:Organization
Organization Name:M & M OF THE CAROLINAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MPA, QP
Authorized Official - Phone:704-832-3760
Mailing Address - Street 1:PO BOX 6254
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-6023
Mailing Address - Country:US
Mailing Address - Phone:704-832-3760
Mailing Address - Fax:704-500-2043
Practice Address - Street 1:151 BEECHWOOD FARM RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9409
Practice Address - Country:US
Practice Address - Phone:704-832-3760
Practice Address - Fax:704-500-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103TP0814X, 251B00000X
NC1195103TH0100X
NC1332103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409332Medicaid
NCCR00088PMedicaid
NC6006119Medicaid
NC8300866GMedicaid
NC8301280Medicaid
NC8301280BMedicaid