Provider Demographics
NPI:1033245709
Name:WILMINGTON HEALTH ACCESS FOR TEENS
Entity Type:Organization
Organization Name:WILMINGTON HEALTH ACCESS FOR TEENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DE BOVENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:910-790-9949
Mailing Address - Street 1:4005 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6816
Mailing Address - Country:US
Mailing Address - Phone:910-790-9949
Mailing Address - Fax:910-790-9455
Practice Address - Street 1:4005 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6816
Practice Address - Country:US
Practice Address - Phone:910-790-9949
Practice Address - Fax:910-790-9455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6005437101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005437Medicaid