Provider Demographics
NPI:1912186735
Name:MAKING A DIFFERENCE COMMUNITY SUPPORT LLC
Entity Type:Organization
Organization Name:MAKING A DIFFERENCE COMMUNITY SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:SHANEQUA
Authorized Official - Middle Name:CORNISE
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-475-9829
Mailing Address - Street 1:PO BOX 7672
Mailing Address - Street 2:
Mailing Address - City:KILL DEVIL HILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27948-6672
Mailing Address - Country:US
Mailing Address - Phone:252-475-9829
Mailing Address - Fax:
Practice Address - Street 1:102 OLD TOM AVE.
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954
Practice Address - Country:US
Practice Address - Phone:252-475-9829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0850X261QM0850X
NC261QM0855X261QM0855X
NC261QR0400X261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health