Provider Demographics
NPI:1700909454
Name:GLORIA CRANDELL-NELSON
Entity type:Organization
Organization Name:GLORIA CRANDELL-NELSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDELL-NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-795-6662
Mailing Address - Street 1:7356 HWY 64 E
Mailing Address - Street 2:
Mailing Address - City:ROBERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27871-0278
Mailing Address - Country:US
Mailing Address - Phone:252-795-6662
Mailing Address - Fax:252-795-6696
Practice Address - Street 1:7356 US HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:ROBERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27871-9073
Practice Address - Country:US
Practice Address - Phone:252-795-6662
Practice Address - Fax:252-795-6696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006991Medicaid
NC5950083Medicaid
NC8301939Medicaid