Provider Demographics
NPI:1821140401
Name:NEW LEAF ADOLESCENT CARE, INC
Entity Type:Organization
Organization Name:NEW LEAF ADOLESCENT CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:704-891-5825
Mailing Address - Street 1:1945 J N PEASE PL STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4555
Mailing Address - Country:US
Mailing Address - Phone:704-405-8890
Mailing Address - Fax:704-405-8893
Practice Address - Street 1:1945 J N PEASE PL STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4555
Practice Address - Country:US
Practice Address - Phone:704-405-8890
Practice Address - Fax:704-405-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8301256B251B00000X
NC251S00000X
NCMHL-060-802320800000X
NCMHL-090-146320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301256BMedicaid
NC060-802Medicaid