Provider Demographics
NPI:1790219871
Name:AFFINITY CLINICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:AFFINITY CLINICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NDUPU
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHCS, CCS, LCAS
Authorized Official - Phone:980-224-8060
Mailing Address - Street 1:5500 EXECUTIVE CENTER DRIVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212
Mailing Address - Country:US
Mailing Address - Phone:980-224-8060
Mailing Address - Fax:704-379-1914
Practice Address - Street 1:5500 EXECUTIVE CENTER DRIVE
Practice Address - Street 2:SUITE 118
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212
Practice Address - Country:US
Practice Address - Phone:980-224-8060
Practice Address - Fax:704-379-1914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4936101YP2500X
251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251X00000XAgenciesSupports Brokerage
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103653Medicaid