Healthcare Provider Details

I. General information

NPI: 1326764929
Provider Name (Legal Business Name): CAROLINA BEHAVIORAL CARE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 CARMEL EXECUTIVE PARK DR STE 155
CHARLOTTE NC
28226-8242
US

IV. Provider business mailing address

PO BOX 1630
PINEHURST NC
28370-1630
US

V. Phone/Fax

Practice location:
  • Phone: 844-534-7208
  • Fax:
Mailing address:
  • Phone: 910-295-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIM WISE
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 910-295-8402