Provider Demographics
NPI:1790860807
Name:MECKLENBURG COUNTY AREA MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:MECKLENBURG COUNTY AREA MENTAL HEALTH AUTHORITY
Other - Org Name:ADULT HOMELESS SUBSTANCE ABUSE TRTMNT-OFFSITE (WOMEN'S)
Other - Org Type:Other Name
Authorized Official - Title/Position:AREA DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRAYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-336-8638
Mailing Address - Street 1:429 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1007
Mailing Address - Country:US
Mailing Address - Phone:794-336-2023
Mailing Address - Fax:704-336-4383
Practice Address - Street 1:534 SPRATT ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2969
Practice Address - Country:US
Practice Address - Phone:704-432-2958
Practice Address - Fax:704-432-4599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-722251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301098GMedicaid
NC8301098PMedicaid