Basic Information
| Provider Information | |||||||||
| NPI: | 1346388782 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMOKY MOUNTAIN CENTER FOR MH/DD/SAS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BALSAM CENTER FOR HOPE AND RECOVERY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 BONNIE LANE | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287798511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285865501 | ||||||||
| FaxNumber: | 8285863965 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 TIMBERLANE DRIVE | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284541098 | ||||||||
| FaxNumber: | 8284549242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 11/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCDEVITT | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | AREA DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8285865501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL 044 039 | NC | N | Agencies | Community/Behavioral Health | 2084P0800X | MHL 044 039 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 5901891 | 05 | NC | MEDICAID |