Basic Information
| Provider Information | |||||||||
| NPI: | 1780734988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORT HUMAN SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2245 STANTONSBURG RD | ||||||||
| Address2: | SUITE P | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278342868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527520483 | ||||||||
| FaxNumber: | 2527522971 | ||||||||
| Practice Location | |||||||||
| Address1: | 2269 STANTONSBURG ROAD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278347826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527520130 | ||||||||
| FaxNumber: | 2527524949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SAVIDGE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2527520483 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | MHL-074-150 | NC | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | MHL-074-150 | NC | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6005362 | 05 | NC | MEDICAID | 016X5 | 01 | NC | BCBS | OTHER |