Provider Demographics
NPI:1295271039
Name:MILESTONE INNOVATIVE SERVICES
Entity type:Organization
Organization Name:MILESTONE INNOVATIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MOORE-HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MSW
Authorized Official - Phone:252-799-1916
Mailing Address - Street 1:618 E BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-2736
Mailing Address - Country:US
Mailing Address - Phone:252-792-0659
Mailing Address - Fax:252-792-0660
Practice Address - Street 1:618 E BOULEVARD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2736
Practice Address - Country:US
Practice Address - Phone:252-792-0659
Practice Address - Fax:252-792-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3185A101YA0400X
101YA0400X, 101YM0800X, 1041C0700X, 251S00000X
NC9919101YM0800X
NCC0100461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1544820OtherSTATE NC