Basic Information
Provider Information | |||||||||
NPI: | 1457657645 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER BEHAVIORAL SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PREMIER BEHAVIORAL SERVICES INC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2003 GODWIN AVENUE | ||||||||
Address2: | SUITE B | ||||||||
City: | LUMBERTON | ||||||||
State: | NC | ||||||||
PostalCode: | 283583197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106711111 | ||||||||
FaxNumber: | 9106714454 | ||||||||
Practice Location | |||||||||
Address1: | 2003 GODWIN AVE | ||||||||
Address2: | SUITE B | ||||||||
City: | LUMBERTON | ||||||||
State: | NC | ||||||||
PostalCode: | 283583197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106711111 | ||||||||
FaxNumber: | 9106714454 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/04/2011 | ||||||||
LastUpdateDate: | 10/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AUGUSTINE | ||||||||
AuthorizedOfficialFirstName: | SANTHOSH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9107332007 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PREMIER BEHAVIORAL SERVICES INC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 10/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C001816 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207R00000X | 9600445 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 2084P0800X | 19520 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.