Basic Information
| Provider Information | |||||||||
| NPI: | 1487796116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E WEAVER ST | ||||||||
| Address2: | SUITE G-7 | ||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275102370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199330770 | ||||||||
| FaxNumber: | 9199330767 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 WEBB ST | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275735338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365996030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | JEFFERSON | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | ACTING EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9199330828 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL-073-031 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8301148 | 05 | NC | MEDICAID | 8301148S | 05 | NC | MEDICAID |