Healthcare Provider Details

I. General information

NPI: 1215179221
Provider Name (Legal Business Name): SOUTHCARE COMMUNITY SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 MARKET ST
WILMINGTON NC
28401-4871
US

IV. Provider business mailing address

1506 MARKET ST
WILMINGTON NC
28401-4871
US

V. Phone/Fax

Practice location:
  • Phone: 910-254-4065
  • Fax: 910-254-4067
Mailing address:
  • Phone: 910-254-4065
  • Fax: 910-254-4067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 12
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. LANEY B HARRILL
Title or Position: PRESIDENT/CEO
Credential:
Phone: 910-368-1928