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General NPI Number Information
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NPI Number | 1487829248
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Entity Type | Organization
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Legal Business Name | EXTENDED REACH DAY TREATMENT FOR CHILDREN AND ADOLESCENTS, LLC
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Dates
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Enumeration Date | 04/23/2008
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Last Update Date | 05/27/2010
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Provider Practice Location Address
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Address Line | 2716 CUSTER AVE
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City | FAYETTEVILLE
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State | NC
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Zip | 28312-7814
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Country | US
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Telephone | 910-484-0095
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Fax | 919-238-7238
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Provider Business Mailing Address
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Address Line | 2716 CUSTER AVE
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City | FAYETTEVILLE
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State | NC
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Zip | 28312-7814
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Country | US
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Telephone | 910-484-0095
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Fax | 919-238-7238
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Authorized Official
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Title or Position | C.E.O
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Name | ANDREA MONIQUE BOATMAN-HALL
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Credential |
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Telephone | 910-229-8256
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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