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Organization
LIFESOURCE OF NORTH CAROLINA
Active
Organization
LIFESOURCE OF NORTH CAROLINA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PEGGY BADDOUR (PRESIDENT)
(910) 777-9165
Entity
Organization
Contact information
Practice address
140 PARK AVE, BLOOMFIELD, CT 06002-3207
(910) 742-9243
(888) 746-1787
Mailing address
PO BOX 538622, ATLANTA, GA 30353-8622
(910) 742-9243
(888) 746-1787
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
—
—
1041C0700X
Clinical Social Worker
Primary
—
—
2084P0800X
Psychiatry Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
03/31/2020
Last updated
03/26/2021
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