Basic Information
| Provider Information | |||||||||
| NPI: | 1386662831 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC ALTERNATIVES INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 814 | ||||||||
| Address2: | 4270 HEATH DAIRY RD | ||||||||
| City: | RANDLEMAN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273170814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364952700 | ||||||||
| FaxNumber: | 3364955552 | ||||||||
| Practice Location | |||||||||
| Address1: | 962 S FAYETTEVILLE ST | ||||||||
| Address2: | |||||||||
| City: | ASHEBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272036410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366261500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | BURROW | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3364952700 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THERAPEUTIC ALTERNATIVES INCORPORATED | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6005330 | 05 | NC | MEDICAID |