Healthcare Provider Details

I. General information

NPI: 1962887281
Provider Name (Legal Business Name): NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 BLUFORD ST.
GREENSBORO NC
27401
US

IV. Provider business mailing address

913 BLUFORD ST.
GREENSBORO NC
27401
US

V. Phone/Fax

Practice location:
  • Phone: 336-285-2605
  • Fax:
Mailing address:
  • Phone: 336-285-2605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA11635
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberA11635
License Number StateNC

VIII. Authorized Official

Name: KRISTIN CHESHIRE
Title or Position: INTAKE SPECIALIST
Credential: LPCA
Phone: 336-285-2605