=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790004208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION BEHAVIORAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2010
-----------------------------------------------------
Last Update Date | 05/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 495 ARBOR HILL RD SUITE E
-----------------------------------------------------
City | KERNERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27284-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-992-0429
-----------------------------------------------------
Fax | 336-993-3709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 495 ARBOR HILL RD SUITE E
-----------------------------------------------------
City | KERNERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27284-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-992-0429
-----------------------------------------------------
Fax | 336-993-3709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MS. SHARON ELIZABETH GARRETT
-----------------------------------------------------
Credential | M.ED.
-----------------------------------------------------
Telephone | 336-992-0429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 200201030
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------