MEDICARE: NORTHEASTERN HUMAN SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	8457098	NC

General Provider Information

NPI Number	:	1033344023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEASTERN HUMAN SERVICES

Provider Business Mailing Address
First Line	:	6316 SAYBROOKE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-1282
Country	:	US
Telephone Number	:	919-878-6764
Fax Number	:	919-878-6764

Provider Business Practice Location Address
First Line	:	6316 SAYBROOKE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-1282
Country	:	US
Telephone Number	:	919-878-6764
Fax Number	:	919-878-6764

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JAMES THOMAS COTTON JR.
Credential	:
Telephone Number	:	919-673-1661

Provider Enumeration Date	:	05/20/2009
Last Update Date	:	05/20/2009

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