# STATEWIDE MENTAL HEALTH & DISABILITY SERVICES PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588942239
- **Authorized official:** KRISTIN CLAYTON (CHIEF EXECUTIVE OFFICER)
- **Authorized official phone:** (252) 308-1247

## Contact information

- **Practice address:** 622 ROANOKE AVE STE A, ROANOKE RAPIDS, NC 27870-2740
- **Practice address phone:** (252) 308-1247
- **Mailing address:** 730 ROANOKE AVENUE, SUITE A-1, ROANOKE RAPIDS, NC 27870-2740
- **Mailing address phone:** (252) 308-1247
- **Mailing address fax:** (252) 308-1248

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 251S00000X | Community/Behavioral Health Agency | COO3950 | NC | Yes |

## Other

- **Enumeration date:** 07/29/2011
- **Last updated:** 07/17/2017

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 6003794 | — | NC |