Provider Demographics
NPI:1831341429
Name:TEAM SUCCESS LLC
Entity type:Organization
Organization Name:TEAM SUCCESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HERBERT
Authorized Official - Suffix:
Authorized Official - Credentials:BBA, MBA
Authorized Official - Phone:704-668-3573
Mailing Address - Street 1:251 N HIGHWAY 16
Mailing Address - Street 2:APT. 14
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-5004
Mailing Address - Country:US
Mailing Address - Phone:704-668-3573
Mailing Address - Fax:
Practice Address - Street 1:3393 STARTOWN RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658-9216
Practice Address - Country:US
Practice Address - Phone:704-668-3573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-018-086322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children