Basic Information
| Provider Information | |||||||||
| NPI: | 1053473991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5171 GLENWOOD AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197838898 | ||||||||
| FaxNumber: | 9197825486 | ||||||||
| Practice Location | |||||||||
| Address1: | 3405 W WENDOVER AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274072377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365456338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | KEY-ALLRED | ||||||||
| AuthorizedOfficialFirstName: | NASHEBA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9197838898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 251S00000X | N | Agencies | Community/Behavioral Health | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 018KJ | 01 | NC | NCBCBS | OTHER | 830127C | 05 | NC | MEDICAID | 8301327 | 05 | NC | MEDICAID | 8301327B | 05 | NC | MEDICAID | 8301327H | 05 | NC | MEDICAID | 8301327I | 05 | NC | MEDICAID | 8301327A | 05 | NC | MEDICAID | 8301327F | 05 | NC | MEDICAID | 8301327G | 05 | NC | MEDICAID |