Healthcare Provider Details

I. General information

NPI: 1144382086
Provider Name (Legal Business Name): EASTERSEALSUCP-ASAP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 TURNERSBURG HWY
STATESVILLE NC
28625-2798
US

IV. Provider business mailing address

134 WIND CHIME CT
RALEIGH NC
27615-6433
US

V. Phone/Fax

Practice location:
  • Phone: 704-402-1060
  • Fax: 704-402-1065
Mailing address:
  • Phone: 919-784-9182
  • Fax: 919-784-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA G SULLIVAN
Title or Position: DIRECTOR OF SUPPORT SERVICES
Credential:
Phone: 919-784-9182