Provider Demographics
| NPI: | 1780974253 |
|---|---|
| Name: | SUPPORT INCORPORATED |
| Entity type: | Organization |
| Organization Name: | SUPPORT INCORPORATED |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JOSH |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | MARTIN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 704-865-3529 |
| Mailing Address - Street 1: | PO BOX 4003 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | GASTONIA |
| Mailing Address - State: | NC |
| Mailing Address - Zip Code: | 28054-0041 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 704-865-3525 |
| Mailing Address - Fax: | 704-865-3520 |
| Practice Address - Street 1: | 708 S CHESTNUT ST |
| Practice Address - Street 2: | |
| Practice Address - City: | GASTONIA |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 28054-4548 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 704-865-3525 |
| Practice Address - Fax: | 704-865-3520 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2011-04-18 |
| Last Update Date: | 2015-12-30 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 261QP2300X, 261QM1300X, 101YA0400X, 101YM0800X, 101YP2500X, 103T00000X, 2084P0804X, 363L00000X, 363LF0000X, 363LP0808X, 363A00000X, 1041C0700X | ||
| NC | MHL-036-292 | 251S00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | Group - Multi-Specialty |
| No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NC | 8303341 | Medicaid | |
| NC | 5918314 | Medicaid | |
| NC | 016V4 | Other | BCBS |
| NC | 6005063 | Medicaid | |
| NC | 016V4 | Other | BCBS |
| NC | 016V4 | Other | BCBS |
| NC | 8303341G | Medicaid |
