MEDICARE: TRIAD BEHAVIORAL RESOURCES

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)	MHL041686	NC

General Provider Information

NPI Number	:	1538495536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIAD BEHAVIORAL RESOURCES

Provider Business Mailing Address
First Line	:	436 SPRING GARDEN ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-2734
Country	:	US
Telephone Number	:	336-389-1413
Fax Number	:	336-389-1416

Provider Business Practice Location Address
First Line	:	436 SPRING GARDEN ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-2734
Country	:	US
Telephone Number	:	336-389-1413
Fax Number	:	336-389-1416

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DAVID BOLTON
Credential	:	MS, LPC
Telephone Number	:	336-389-1413

Provider Enumeration Date	:	10/26/2009
Last Update Date	:	10/26/2009

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