Basic Information
| Provider Information | |||||||||
| NPI: | 1477882694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORT HUMAN SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4300-110 SAPPHIRE COURT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278349019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | 2524130930 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278581801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527522431 | ||||||||
| FaxNumber: | 2525618080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2009 | ||||||||
| LastUpdateDate: | 12/17/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAVIDGE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2528307540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | MHL 074-145 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.