Provider Demographics
NPI:1235940321
Name:IMPACT CHILD BEHAVIORAL SERVICES, INC.
Entity type:Organization
Organization Name:IMPACT CHILD BEHAVIORAL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-773-8115
Mailing Address - Street 1:16325 NORTHCROSS DR STE A
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5044
Mailing Address - Country:US
Mailing Address - Phone:704-773-8115
Mailing Address - Fax:
Practice Address - Street 1:16325 NORTHCROSS DR STE A
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5044
Practice Address - Country:US
Practice Address - Phone:704-773-8115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-16
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251E00000XAgenciesHome Health