=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295874527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODBRIDGE ALTERNATIVE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 04/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1480 PAMALEE DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-3928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-488-9570
-----------------------------------------------------
Fax | 910-822-0111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1480 PAMALEE DRIIVE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-3928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-488-9570
-----------------------------------------------------
Fax | 910-822-0111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MR. LEON ROBINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-488-9570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026718
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026705
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026680
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL065161
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL065155
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026477
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026464
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026707
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026454
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL009019
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026557
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #13
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL026618
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #14
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL024052
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #15
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------