Basic Information
| Provider Information | |||||||||
| NPI: | 1306167713 | ||||||||
| 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: | 4000 WAKE FOREST RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197838898 | ||||||||
| FaxNumber: | 9197825486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2010 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | BEAVERS | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9192107661 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300673 | 05 | NC | MEDICAID | 8300676 | 05 | NC | MEDICAID | 8301327 | 05 | NC | MEDICAID | 8301523 | 05 | NC | MEDICAID | 8300675 | 05 | NC | MEDICAID | 8300746 | 05 | NC | MEDICAID | 8301522 | 05 | NC | MEDICAID | 8300672 | 05 | NC | MEDICAID | 8300709 | 05 | NC | MEDICAID | 8300488 | 05 | NC | MEDICAID |