Provider Demographics
NPI:1639561194
Name:SUCCESSFUL MINDS, LLC
Entity type:Organization
Organization Name:SUCCESSFUL MINDS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BURSTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MED
Authorized Official - Phone:704-431-8100
Mailing Address - Street 1:2134 CAPERNIUM RD
Mailing Address - Street 2:TR#2
Mailing Address - City:CHERRYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28021-9478
Mailing Address - Country:US
Mailing Address - Phone:704-769-4075
Mailing Address - Fax:704-769-4136
Practice Address - Street 1:2134 CAPERNIUM RD
Practice Address - Street 2:TR#2
Practice Address - City:CHERRYVILLE
Practice Address - State:NC
Practice Address - Zip Code:28021-9478
Practice Address - Country:US
Practice Address - Phone:704-769-4075
Practice Address - Fax:704-769-4136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC252Y00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency