Provider Demographics
NPI:1083615777
Name:SRRC PSYCHOLOGY
Entity Type:Organization
Organization Name:SRRC PSYCHOLOGY
Other - Org Name:SRRC PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP MANAGED CARE AND REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:B
Authorized Official - Last Name:FISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-615-5572
Mailing Address - Street 1:PO BOX 40908
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-0908
Mailing Address - Country:US
Mailing Address - Phone:910-609-6448
Mailing Address - Fax:910-609-7040
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-609-6440
Practice Address - Fax:910-609-5365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0213103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005389Medicaid
NC2352754Medicare ID - Type UnspecifiedPROVIDER NUMBER