Basic Information
Provider Information | |||||||||
NPI: | 1194887695 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTER SEALS UCP NC & VA, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EASTER SEALS UCP NC & VA, INC | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 414 W LEBANON ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT AIRY | ||||||||
State: | NC | ||||||||
PostalCode: | 270302954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367867079 | ||||||||
FaxNumber: | 3367866312 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2006 | ||||||||
LastUpdateDate: | 08/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KEY-ALLRED | ||||||||
AuthorizedOfficialFirstName: | NASHEBA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 9198658632 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 9901371 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 018KJ | 01 | NC | NC BCBS GROUP PROVIDER NU | OTHER | 5903514 | 05 | NC |   | MEDICAID |