Organization
LIFESOURCE OF NORTH CAROLINA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PEGGY BADDOUR PRESIDENT (PRESIDENT)
(910) 777-9165
Entity
Organization
Contact information
Practice address
5530 NORTHROP RD, MILTON, FL 32570-8701
(910) 742-9243
Mailing address
PO BOX 538622, ATLANTA, GA 30353-8622
(910) 794-4521
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
1041C0700X
Clinical Social Worker
—
—
2084P0800X
Psychiatry Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Enumeration date
03/14/2019
Last updated
03/25/2021
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