1750309662 NPI number — BEACON BEHAVIORAL HEALTH, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750309662 NPI number — BEACON BEHAVIORAL HEALTH, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON BEHAVIORAL HEALTH, 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:
1750309662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27571-0370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-880-7613
Provider Business Mailing Address Fax Number:
919-366-9705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3207 ROGERS RD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-880-7613
Provider Business Practice Location Address Fax Number:
919-366-9705
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FALK
Authorized Official First Name:
RONDA
Authorized Official Middle Name:
O
Authorized Official Title or Position:
MEMBER MANAGER
Authorized Official Telephone Number:
919-880-7613

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C004632 , 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: 136FC . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6002797 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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