Basic Information
| Provider Information | |||||||||
| NPI: | 1023139490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEDROW | ||||||||
| FirstName: | JIM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 RIDGE STREET | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27577 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 RIDGE STREET | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197519120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 858 NC | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6107238 | 05 | NC | MEDICAID | 56-1693916 | 01 | NC | TAX ID | OTHER |