Healthcare Provider Details

I. General information

NPI: 1467439661
Provider Name (Legal Business Name): NORTH STATE CONSORTIUM FOR PSYCHOSOCIAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 JONES FERRY RD UNIT J
CARRBORO NC
27510-2036
US

IV. Provider business mailing address

1419 CRAWFORD DAIRY RD UNIT C
CHAPEL HILL NC
27516-8521
US

V. Phone/Fax

Practice location:
  • Phone: 919-942-0858
  • Fax:
Mailing address:
  • Phone: 919-942-0858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GLEN TIG
Title or Position: DIRECTOR
Credential: MA
Phone: 919-924-0858