Basic Information
| Provider Information | |||||||||
| NPI: | 1023150968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROBESON HEALTH CARE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAMBRIDGE PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 COMMERCE PLAZA CIR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283727386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105212900 | ||||||||
| FaxNumber: | 9107759165 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 CAMBRIDGE PL | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199898114 | ||||||||
| FaxNumber: | 9199380503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BEHAVIORAL HEALTH SVCS | ||||||||
| AuthorizedOfficialTelephone: | 9105212900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MDIV | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MHL-051-139 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | MHL-051-139 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300616P | 05 | NC | MEDICAID | 8300616 | 05 | NC | MEDICAID | 8300616B | 05 | NC | MEDICAID | 8300616G | 05 | NC | MEDICAID | 6005788 | 05 | NC | MEDICAID |