Basic Information
| Provider Information | |||||||||
| NPI: | 1144382086 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERSEALSUCP-ASAP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AREA SERVICES AND PROGRAMS INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 WIND CHIME CT | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197849182 | ||||||||
| FaxNumber: | 9197849184 | ||||||||
| Practice Location | |||||||||
| Address1: | 318 TURNERSBURG HWY | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286252798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044021060 | ||||||||
| FaxNumber: | 7044021065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF SUPPORT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9197849182 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 5902828 | 05 | NC | MEDICAID |