=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730740184
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAMLICO RIVER BEHAVIORAL HEALTH, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2019
-----------------------------------------------------
Last Update Date | 01/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E MAIN ST
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27889-4928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-940-1611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 S RESPESS ST
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27889-4956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-623-2736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MARTHA EARLY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 252-623-2736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------