=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508801663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANTAGE PSYCHIATRY & COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 OLD WATERFORD WAY STE 1C
-----------------------------------------------------
City | LELAND
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28451-4102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-371-1007
-----------------------------------------------------
Fax | 910-371-6003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1003 OLD WATERFORD WAY STE 1C
-----------------------------------------------------
City | LELAND
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28451-4102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-371-1007
-----------------------------------------------------
Fax | 910-371-6003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RUSSELL HERRING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-371-1007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------