=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831592864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICORP BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2014
-----------------------------------------------------
Last Update Date | 03/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 W MILLBROOK RD STE F
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-4381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-329-2630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 MAIN ST STE 300
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-3266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-696-6071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. IGNACIO KIRK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-696-6071
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C 000396
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-09-2503
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------