Basic Information
| Provider Information | |||||||||
| NPI: | 1194888016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA PROFESSIONAL MENTAL HEALTH ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 N COURT SQ | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283585554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102729356 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 N COURT SQ | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283585554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102729356 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | JONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASST. DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9102729356 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PLCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 5905355 | 05 | NC | MEDICAID | 6106443 | 05 | NC | MEDICAID | 8300659 | 05 | NC | MEDICAID | 8300659G | 05 | NC | MEDICAID | 6103405 | 05 | NC | MEDICAID | 3408172 | 05 | NC | MEDICAID | 8300659B | 05 | NC | MEDICAID | 8300659H | 05 | NC | MEDICAID | 6005977 | 05 | NC | MEDICAID | 8300659R | 05 | NC | MEDICAID | 5901420 | 05 | NC | MEDICAID |