Healthcare Provider Details

I. General information

NPI: 1417080441
Provider Name (Legal Business Name): THE MENTAL HEALTH ASSOCIATION IN NORTH CAROLINA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E BOSTON AVE
PINEBLUFF NC
28373-8033
US

IV. Provider business mailing address

1331 SUNDAY DR
RALEIGH NC
27607
US

V. Phone/Fax

Practice location:
  • Phone: 910-281-5327
  • Fax:
Mailing address:
  • Phone: 919-981-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-063-009
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier8300426S
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MR. KEVIN COCHRAN
Title or Position: FINANCIAL ASSISTANT
Credential:
Phone: 919-981-0740