Healthcare Provider Details

I. General information

NPI: 1952538944
Provider Name (Legal Business Name): EARLY ADOLESCENT INTERVENTIONS SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MAIN STREET
SPRING HOPE NC
27882-1384
US

IV. Provider business mailing address

101 E MAIN STREET
SPRING HOPE NC
27882-1384
US

V. Phone/Fax

Practice location:
  • Phone: 252-724-2319
  • Fax:
Mailing address:
  • Phone: 252-724-2319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. SHAMELYA ENGLAND WATSON
Title or Position: CEO
Credential: BA, QP
Phone: 252-724-2319