=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861838492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2013
-----------------------------------------------------
Last Update Date | 05/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10150 MALLARD CREEK RD SUITE 510
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-9708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-333-8220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 WEBB BLVD PO BOX 629
-----------------------------------------------------
City | HAVELOCK
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28532-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-447-3892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP SERVICE LINE
-----------------------------------------------------
Name | RICHARD EDWARDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-783-8898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------