Basic Information
Provider Information | |||||||||
NPI: | 1710275409 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ONE LOVE PERIODIC SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 NORTH GREEN STREET | ||||||||
Address2: |   | ||||||||
City: | MORGANTON | ||||||||
State: | NC | ||||||||
PostalCode: | 286553483 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284334567 | ||||||||
FaxNumber: | 8284334576 | ||||||||
Practice Location | |||||||||
Address1: | 103 N GREEN ST | ||||||||
Address2: |   | ||||||||
City: | MORGANTON | ||||||||
State: | NC | ||||||||
PostalCode: | 286553466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284334567 | ||||||||
FaxNumber: | 8284334576 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2011 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WIDEMAN | ||||||||
AuthorizedOfficialFirstName: | STEVIE | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8284334567 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | N |   | Agencies | Case Management |   | 253J00000X |   | NC | N |   | Agencies | Foster Care Agency |   | 322D00000X | MHL-012-095 | NC | N |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   | 253J00000X |   |   | N |   | Agencies | Foster Care Agency |   | 101YP2500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 6008242 | 05 | NC |   | MEDICAID | 8301457H | 05 | NC |   | MEDICAID | 5916270 | 05 | NC |   | MEDICAID | 8301457V | 05 | NC |   | MEDICAID | 3410218 | 05 | NC |   | MEDICAID | 6603804 | 05 | NC |   | MEDICAID | 8703220 | 05 | NC |   | MEDICAID |