Basic Information
| Provider Information | |||||||||
| NPI: | 1689719296 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER BEHAVIORAL SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PREMIER BEHAVIORAL SERVICES INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 GODWIN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106711111 | ||||||||
| FaxNumber: | 9106714454 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 GODWIN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106711111 | ||||||||
| FaxNumber: | 9106714454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AUGUSTINE | ||||||||
| AuthorizedOfficialFirstName: | SANTHOSH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9107332007 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER BEHAVIORAL SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3408672 | 05 | NC | MEDICAID | 8300573G | 05 | NC | MEDICAID | 6006152 | 05 | NC | MEDICAID | 8300573H | 05 | NC | MEDICAID | 8300573B | 05 | NC | MEDICAID |