=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245414184
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPASS ADULT CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 12/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 RIDGEFIELD BLVD SUITE 190
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28806-6209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-521-4977
-----------------------------------------------------
Fax | 704-521-8541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 19649
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28219-9649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-521-4977
-----------------------------------------------------
Fax | 704-521-8541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DEREK BULLARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-521-4977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------