Healthcare Provider Details

I. General information

NPI: 1083911820
Provider Name (Legal Business Name): FIFTH RIVER MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 HIGHLAND OAKS DR SUITE 202
WINSTON SALEM NC
27103-7106
US

IV. Provider business mailing address

1112 OAKENCROFT CT
LEWISVILLE NC
27023-8727
US

V. Phone/Fax

Practice location:
  • Phone: 336-608-4060
  • Fax: 336-665-8188
Mailing address:
  • Phone: 336-608-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: DR. GISELA E KNEBL KOHL
Title or Position: PRESIDENT
Credential: MD
Phone: 954-558-3608