Provider Demographics
NPI:1023187473
Name:UNCG PSYCHOLOGY CLINIC
Entity Type:Organization
Organization Name:UNCG PSYCHOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN, COLLGE OF ARTS & SCIENCES
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-256-0065
Mailing Address - Street 1:PO BOX 26170
Mailing Address - Street 2:UNCG CAMPUS
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27402-6170
Mailing Address - Country:US
Mailing Address - Phone:336-334-5662
Mailing Address - Fax:336-334-5754
Practice Address - Street 1:1100 W MARKET ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1830
Practice Address - Country:US
Practice Address - Phone:336-334-5662
Practice Address - Fax:336-334-5754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005278Medicaid
NC5903678Medicaid
NC5903678Medicaid