Basic Information
Provider Information | |||||||||
NPI: | 1851752869 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | APPALACHIAN OUTPATIENT SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TAPESTRY EATING DISORDER PROGRAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 119 TUNNEL RD STE B | ||||||||
Address2: |   | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288051800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8283501000 | ||||||||
FaxNumber: | 8283501300 | ||||||||
Practice Location | |||||||||
Address1: | 11 N COUNTRY CLUB RD | ||||||||
Address2: |   | ||||||||
City: | BREVARD | ||||||||
State: | NC | ||||||||
PostalCode: | 287128908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8288842475 | ||||||||
FaxNumber: | 8288842187 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2016 | ||||||||
LastUpdateDate: | 07/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUSTED | ||||||||
AuthorizedOfficialFirstName: | CHAD | ||||||||
AuthorizedOfficialMiddleName: | RYAN | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 7706399654 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL088023 | NC | N |   | Agencies | Community/Behavioral Health |   | 261QM0850X | MHL-088-023 | NC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
ID | Type | State | Issuer | Description | MHL-088-023 | 01 | NC | MHL-088-023 | OTHER |