Provider Demographics
NPI:1265058341
Name:HART, SHIRLEY (DIRECTOR)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E ELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-2940
Mailing Address - Country:US
Mailing Address - Phone:910-273-6137
Mailing Address - Fax:
Practice Address - Street 1:708 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-2218
Practice Address - Country:US
Practice Address - Phone:910-273-6137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC57-1203135Medicaid