Provider Demographics
NPI:1689710162
Name:UNIQUELY SUPPORTED
Entity Type:Organization
Organization Name:UNIQUELY SUPPORTED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-289-4333
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28042-0690
Mailing Address - Country:US
Mailing Address - Phone:704-538-3648
Mailing Address - Fax:704-538-6940
Practice Address - Street 1:2904 PHILADELPHIA RD
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:NC
Practice Address - Zip Code:28090-9461
Practice Address - Country:US
Practice Address - Phone:704-538-3648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805267Medicaid
NC7805274Medicaid
NC7805276Medicaid
NC7805279Medicaid
NC7805317Medicaid
NC7805295Medicaid
NC7805318Medicaid
NC7805296Medicaid
NC7805143Medicaid
NC7805278Medicaid
NC7805316Medicaid
NC7805275Medicaid