Provider Demographics
NPI:1891882528
Name:MECKLENBURG COUNTY AREA MH, DD AND SA AUTHORITY
Entity Type:Organization
Organization Name:MECKLENBURG COUNTY AREA MH, DD AND SA AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AREA DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRAYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
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:704-336-2023
Mailing Address - Fax:704-336-8591
Practice Address - Street 1:429 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1007
Practice Address - Country:US
Practice Address - Phone:704-336-2023
Practice Address - Fax:704-336-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404913Medicaid
NC3404913PMedicaid
NC6005610OtherMULTI-SPECIALTY GROUP
NC3404913MMedicaid
NC6005609OtherMULTI-SPECIALTY GROUP