1346477403 NPI number — BROADSTEP BEHAVIORAL HEALTH

Table of content: (NPI 1346477403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346477403 NPI number — BROADSTEP BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADSTEP BEHAVIORAL HEALTH
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:
COASTAL SOUTHEASTERN UNITED CARE
Provider Other Organization Name Type Code:
3
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:
1346477403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 COMMERCE AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MOREHEAD CITY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-773-0195
Provider Business Mailing Address Fax Number:
252-773-0214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 DOCTORS CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
SUPPLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-755-5222
Provider Business Practice Location Address Fax Number:
910-755-5255
Provider Enumeration Date:
06/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ATKINSON
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
ASHLEY
Authorized Official Title or Position:
VP, HOME AND COMMUNITY SERVICES
Authorized Official Telephone Number:
843-806-2695

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 8302940 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302940B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302940H , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: B913 . This is a "MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8302940G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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