Basic Information
| Provider Information | |||||||||
| NPI: | 1881822344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORT HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORT HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300-110 SAPPHIRE COURT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | 2524130932 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ARPDC ST | ||||||||
| Address2: | |||||||||
| City: | HERTFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279447901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524261689 | ||||||||
| FaxNumber: | 2524261948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | ROUNTREE | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2528307540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.