1336191444 NPI number — PSYCHOLOGICAL HEALTH SERVICES, PC

Table of content: (NPI 1336191444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336191444 NPI number — PSYCHOLOGICAL HEALTH SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGICAL HEALTH SERVICES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336191444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 FAIRFAX RD
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27407-3009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-297-1981
Provider Business Mailing Address Fax Number:
336-297-1983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 FAIRFAX RD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27407-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-297-1981
Provider Business Practice Location Address Fax Number:
336-297-1983
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEMATI
Authorized Official First Name:
MARY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-297-1981

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2642 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: E3524 . This is a "MEDCOST PROVIDER NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1336191444 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6000189 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 045HP . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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