Provider Demographics
NPI:1649558933
Name:PELHAM SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:PELHAM SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-630-6757
Mailing Address - Street 1:949 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-2907
Mailing Address - Country:US
Mailing Address - Phone:910-630-6757
Mailing Address - Fax:910-884-9804
Practice Address - Street 1:315 A WEST BROAD STREET
Practice Address - Street 2:
Practice Address - City:ST PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384-1535
Practice Address - Country:US
Practice Address - Phone:910-865-3358
Practice Address - Fax:910-865-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMNL-078-284251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health