=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174755938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENSIVE MENTAL CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2009
-----------------------------------------------------
Last Update Date | 10/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 OCEAN HWY S
-----------------------------------------------------
City | HERTFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27944-7902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-426-1390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1207
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27588-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-426-1390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | VALERIE C COSTEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-333-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------