Provider Demographics
NPI:1073816294
Name:BARBOUR, CARLIE (PSYD)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:
Last Name:BARBOUR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PINK HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28572-7986
Mailing Address - Country:US
Mailing Address - Phone:252-268-0597
Mailing Address - Fax:
Practice Address - Street 1:70 CRAPE MYRTLE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-8034
Practice Address - Country:US
Practice Address - Phone:919-938-0875
Practice Address - Fax:919-934-0266
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1715103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ48977AMedicare PIN