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

General Provider Information

NPI Number	:	1982996674
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	:

Provider Business Practice Location Address
First Line	:	824 GUM BRANCH RD
Second Line	:	SUITES C & D
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-6272
Country	:	US
Telephone Number	:	910-347-9111
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	RICHARD EDWARDS
Credential	:
Telephone Number	:	919-783-8898

Provider Enumeration Date	:	05/12/2011
Last Update Date	:	05/12/2011

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