Healthcare Provider Details

I. General information

NPI: 1174755938
Provider Name (Legal Business Name): INTENSIVE MENTAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 OCEAN HWY S
HERTFORD NC
27944-7902
US

IV. Provider business mailing address

PO BOX 1207
WAKE FOREST NC
27588-1207
US

V. Phone/Fax

Practice location:
  • Phone: 252-426-1390
  • Fax:
Mailing address:
  • Phone: 252-426-1390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: VALERIE C COSTEN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 252-333-0500