Healthcare Provider Details

I. General information

NPI: 1083169080
Provider Name (Legal Business Name): THE CENTER FOR EMOTIONAL & BEHAVIORAL CHANGE, INC. (CEBC)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 LONG VIEW DR
YOUNGSVILLE NC
27596-6610
US

IV. Provider business mailing address

610 LONG VIEW DR
YOUNGSVILLE NC
27596-6610
US

V. Phone/Fax

Practice location:
  • Phone: 803-361-0506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMEERA ALI
Title or Position: MANAGER
Credential:
Phone: 678-793-1383