Basic Information
Provider Information | |||||||||
NPI: | 1124185657 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5171 GLENWOOD AVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276123266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197838898 | ||||||||
FaxNumber: | 9197825486 | ||||||||
Practice Location | |||||||||
Address1: | 4000 WAKE FOREST RD | ||||||||
Address2: | STE 200 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276096879 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198611600 | ||||||||
FaxNumber: | 9198611637 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2007 | ||||||||
LastUpdateDate: | 11/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDWARDS | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACT ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9197838898 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 101YM0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 8300673 | 05 | NC |   | MEDICAID | 8300673H | 05 | NC |   | MEDICAID | 8300673A | 05 | NC |   | MEDICAID | 8300673F | 05 | NC |   | MEDICAID | 018KJ | 01 | NC | NCBCBS | OTHER | 8300673B | 05 | NC |   | MEDICAID | 8300673G | 05 | NC |   | MEDICAID | 8300673I | 05 | NC |   | MEDICAID |