Healthcare Provider Details

I. General information

NPI: 1003432121
Provider Name (Legal Business Name): NORTH CAROLINA NEUROPSYCHIATRY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 ENERGY DR
APEX NC
27502-8722
US

IV. Provider business mailing address

2080 ENERGY DR
APEX NC
27502-8722
US

V. Phone/Fax

Practice location:
  • Phone: 919-328-5573
  • Fax: 984-235-1617
Mailing address:
  • Phone: 919-328-5573
  • Fax: 984-235-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier230707
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: TIFFANY CLARK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 919-785-5055