Basic Information
Provider Information | |||||||||
NPI: | 1447390703 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTER SEALS UCP ASAP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AREA SERVICES AND PROGRAMS INC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3801 LAKE BOONE TRL | ||||||||
Address2: | SUITE 320 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276072934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198658772 | ||||||||
FaxNumber: | 9197849184 | ||||||||
Practice Location | |||||||||
Address1: | 214 BEAMAN ST | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | NC | ||||||||
PostalCode: | 283282906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9105962221 | ||||||||
FaxNumber: | 9105962229 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2007 | ||||||||
LastUpdateDate: | 09/23/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SULLIVAN | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF SUPPORT SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9198658772 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 8300710 | 05 | NC |   | MEDICAID | 8300710I | 05 | NC |   | MEDICAID | 8300710G | 05 | NC |   | MEDICAID | 8300710H | 05 | NC |   | MEDICAID | 8300710A | 05 | NC |   | MEDICAID | 8300710B | 05 | NC |   | MEDICAID | 018KJ | 01 | NC | NC BCBS | OTHER | 8300710F | 05 | NC |   | MEDICAID |