MEDICARE: EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.

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	101YM0800X	Mental Health Counselor
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	018KJ	OTHER	NC	NC BCBS GROUP PROVIDER NU

General Provider Information

NPI Number	:	1568524031
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.

Provider Business Mailing Address
First Line	:	5171 GLENWOOD AVE
Second Line	:	SUITE 400
City	:	RALEIGH
State	:	NC
Zip	:	27612-3266
Country	:	US
Telephone Number	:	919-783-8898
Fax Number	:	919-782-5486

Provider Business Practice Location Address
First Line	:	3608 UNIVERSITY DR
Second Line	:	SUITE 101
City	:	DURHAM
State	:	NC
Zip	:	27707-6260
Country	:	US
Telephone Number	:	919-433-0170
Fax Number	:	919-433-0156

Authorized Official
Title or Position	:	CONTRACT ADMINISTRATOR
Name	:	MR. RICHARD P EDWARDS
Credential	:
Telephone Number	:	919-783-8898

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	11/20/2015

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