Basic Information
| Provider Information | |||||||||
| NPI: | 1891861530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPILLMAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311-4E JUDGES ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Practice Location | |||||||||
| Address1: | 311-4E JUDGES ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2751 | TN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 3958 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3680020 | 05 | TN | MEDICAID | 6001248 | 05 | NC | MEDICAID |