MEDICARE: SOUTHERN PSYCHOLOGY P A

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	3032	NC

General Provider Information

NPI Number	:	1285857433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PSYCHOLOGY P A

Provider Business Mailing Address
First Line	:	3500 WESTGATE DR
Second Line	:	SUITE 601
City	:	DURHAM
State	:	NC
Zip	:	27707-2567
Country	:	US
Telephone Number	:	919-419-0900
Fax Number	:	919-419-0991

Provider Business Practice Location Address
First Line	:	3500 WESTGATE DR
Second Line	:	SUITE 601
City	:	DURHAM
State	:	NC
Zip	:	27707-2567
Country	:	US
Telephone Number	:	919-419-0900
Fax Number	:	919-419-0991

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. KATHARINE V RALEIGH
Credential	:	PH.D., M.P.H.
Telephone Number	:	919-419-0900

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/28/2009

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