1407090707 NPI number — SOUTHEAST PSYCHOLOGICAL SERVICES PLLC

Table of content: (NPI 1407090707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407090707 NPI number — SOUTHEAST PSYCHOLOGICAL SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST PSYCHOLOGICAL SERVICES PLLC
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:
1407090707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6115 PARK SOUTH DR
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-3269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-552-0116
Provider Business Mailing Address Fax Number:
704-552-7550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8840 BLAKENEY PROFESSIONAL DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-6718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-552-0116
Provider Business Practice Location Address Fax Number:
704-552-7550
Provider Enumeration Date:
04/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
IYOOB
Authorized Official First Name:
JANET
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
704-552-0116

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  5021 , 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: 6005111 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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