Provider Demographics
NPI:1922277417
Name:ABC OF NC CHILD DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:ABC OF NC CHILD DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SELENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:336-251-1180
Mailing Address - Street 1:905 FRIEDBERG CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-9803
Mailing Address - Country:US
Mailing Address - Phone:336-251-1180
Mailing Address - Fax:336-251-1181
Practice Address - Street 1:905 FRIEDBERG CHURCH RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9803
Practice Address - Country:US
Practice Address - Phone:336-251-1180
Practice Address - Fax:336-251-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1084186103K00000X
122977103K00000X
0125034103K00000X
NC4074103TC0700X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty