MEDICARE: EASTER SEALS UCP ASAP INC

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	018KJ	OTHER	NC	NC BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932266467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS UCP ASAP INC

Provider Business Mailing Address
First Line	:	3801 LAKE BOONE TRL
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-2934
Country	:	US
Telephone Number	:	919-784-9182
Fax Number	:	919-784-9184

Provider Business Practice Location Address
First Line	:	134 WIND CHIME CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27615-6433
Country	:	US
Telephone Number	:	919-784-9182
Fax Number	:	919-784-9184

Authorized Official
Title or Position	:	DIRECTOR OF SUPPORT SERVICES
Name	:	MRS. LISA G SULLLIVAN
Credential	:
Telephone Number	:	919-784-9182

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	08/22/2020

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Practice Location Address:

134 WIND CHIME CT
RALEIGH, NC
27615-6433

Practice Phone: 919-784-9182
Practice Fax: 919-784-9184

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