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NPI Code Detail

MEDICARE: PEDIATRIC AND FAMILY BEHAVIORAL HEALTH, PLLC

MEDICARE: PEDIATRIC AND FAMILY BEHAVIORAL HEALTH, PLLC
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
1101YA0400XAddiction (Substance Use Disorder) Counselor
2363A00000XPhysician Assistant
3363LP0808XPsychiatric/Mental Health Nurse Practitioner
42084P0804XChild & Adolescent Psychiatry Physician2012-01513NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11700385507OTHERNCNPI

General Provider Information

NPI Number : 1700385507
Entity Type Code : Organization
Provider Name (Legal Business Name) : PEDIATRIC AND FAMILY BEHAVIORAL HEALTH, PLLC
Provider Business Mailing Address
First Line : 1111 CIRCLE DR
Second Line :
City : MONROE
State : NC
Zip : 28112-5834
Country : US
Telephone Number : 704-764-1818
Fax Number : 704-285-2222
Provider Business Practice Location Address
First Line : 1111 CIRCLE DR
Second Line :
City : MONROE
State : NC
Zip : 28112-5834
Country : US
Telephone Number : 704-764-1818
Fax Number : 704-285-2222
Authorized Official
Title or Position : OFFICE MANAGER
Name : LISBETH IVELISSE LEGER DE BETANCOURT
Credential :
Telephone Number : 704-764-1818
Provider Enumeration Date : 02/07/2018
Last Update Date : 06/08/2021

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