Provider Demographics
NPI:1003972050
Name:HINES, LARRY LONEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LONEL
Last Name:HINES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OAK BRANCHES CLOSE
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-9562
Mailing Address - Country:US
Mailing Address - Phone:252-258-5920
Mailing Address - Fax:
Practice Address - Street 1:2245 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2868
Practice Address - Country:US
Practice Address - Phone:252-258-5920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1468103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1468OtherNC LICENSE NUMBER
NC6000392Medicaid
NC03196OtherBCBS ID NUMBER
NC2819931AMedicare ID - Type Unspecified