MEDICARE: PERKINS PARTIAL HOSPITAL PROGRAM, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1427612894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERKINS PARTIAL HOSPITAL PROGRAM, PLLC

Provider Business Mailing Address
First Line	:	203 CAPCOM AVE STE 104
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-6514
Country	:	US
Telephone Number	:	919-276-4804
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 CAPCOM AVE STE 104
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-6514
Country	:	US
Telephone Number	:	919-276-4804
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. SHANTEL SULLIVAN
Credential	:
Telephone Number	:	919-276-4804

Provider Enumeration Date	:	04/30/2019
Last Update Date	:	06/11/2024

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