Provider Demographics
NPI:1790923217
Name:ESSENTIAL SUPPORTIVE SERVICES, LLC
Entity Type:Organization
Organization Name:ESSENTIAL SUPPORTIVE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLDSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-550-0639
Mailing Address - Street 1:112 S. ELLINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-6566
Mailing Address - Country:US
Mailing Address - Phone:919-550-0639
Mailing Address - Fax:919-550-0993
Practice Address - Street 1:112 S ELLINGTON ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2306
Practice Address - Country:US
Practice Address - Phone:919-550-0639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare