Healthcare Provider Details

I. General information

NPI: 1568215408
Provider Name (Legal Business Name): EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N PINE ST
ABERDEEN NC
28315-2732
US

IV. Provider business mailing address

5171 GLENWOOD AVE STE 211
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 910-944-2189
  • Fax:
Mailing address:
  • Phone: 919-783-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRETT TURNER BEAVERS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 919-210-7661