Provider Demographics
NPI:1710275409
Name:ONE LOVE PERIODIC SERVICES, INC
Entity Type:Organization
Organization Name:ONE LOVE PERIODIC SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-433-4567
Mailing Address - Street 1:103 NORTH GREEN STREET
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-3483
Mailing Address - Country:US
Mailing Address - Phone:828-433-4567
Mailing Address - Fax:828-433-4576
Practice Address - Street 1:103 N GREEN ST
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-3466
Practice Address - Country:US
Practice Address - Phone:828-433-4567
Practice Address - Fax:828-433-4576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 2084P0800X, 251B00000X, 251S00000X, 253J00000X
NC253J00000X
NCMHL-012-095322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No253J00000XAgenciesFoster Care AgencyGroup - Multi-Specialty
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008242Medicaid
NC8301457HMedicaid
NC5916270Medicaid
NC8301457VMedicaid
NC3410218Medicaid
NC6603804Medicaid
NC8703220Medicaid