=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982756136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIXTH AVENUE PSYCHIATRIC REHABILITATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 N JUSTICE ST
-----------------------------------------------------
City | HENDERSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28739-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-697-9765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 6TH AVE W
-----------------------------------------------------
City | HENDERSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28739-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTRATOR
-----------------------------------------------------
Name | MARY JO STARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-697-1581
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------