Basic Information
| Provider Information | |||||||||
| NPI: | 1962556696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS UCP NORTH CAROLINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282128858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045666040 | ||||||||
| FaxNumber: | 7049712537 | ||||||||
| Practice Location | |||||||||
| Address1: | 3405 W WENDOVER AVE STE H | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274071525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362729602 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | KEY-ALLRED | ||||||||
| AuthorizedOfficialFirstName: | NASHEBA | ||||||||
| AuthorizedOfficialMiddleName: | YVETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9198658632 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8301056B | 05 | NC | MEDICAID | 8301056G | 05 | NC | MEDICAID | 8301056H | 05 | NC | MEDICAID | 8301056I | 05 | NC | MEDICAID |