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General NPI Number Information
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NPI Number | 1740587591
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Entity Type | Organization
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Legal Business Name | EXTENDED REACH DAYTREATMENT FOR CHILDRENA AND ADOLESCENTS LLC
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Dates
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Enumeration Date | 02/14/2011
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Last Update Date | 02/14/2011
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Provider Practice Location Address
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Address Line | 302 BRADFORD AVE
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City | FAYETTEVILLE
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State | NC
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Zip | 28301-5406
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Country | US
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Telephone | 910-484-0095
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Fax | 919-238-7287
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Provider Business Mailing Address
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Address Line | 302 BRADFORD AVE
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City | FAYETTEVILLE
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State | NC
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Zip | 28301-5406
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Country | US
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Telephone | 910-484-0095
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. 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 | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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