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Organization

MAKING A DIFFERENCE COMMUNITY SUPPORT LLC

Active
Organization subpart
No

Provider details

NPI number
Authorized official
SHANEQUA CORNISE BENTON (MEMBER/ORGANIZER)
(252) 475-9829
Entity
Organization

Contact information

Practice address
102 OLD TOM AVE., MANTEO, NC 27954
(252) 475-9829
Mailing address
PO BOX 7672, KILL DEVIL HILLS, NC 27948-6672
(252) 475-9829

Taxonomy

Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
261QM0850X
NC
261QM0855X
Adolescent and Children Mental Health Clinic/Center
261QM0855X
NC
261QR0400X
Rehabilitation Clinic/Center
Primary
261QR0400X
NC

Other

Enumeration date
10/29/2007
Last updated
11/01/2007
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