Provider Demographics
NPI:1083911820
Name:FIFTH RIVER MENTAL HEALTH
Entity Type:Organization
Organization Name:FIFTH RIVER MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GISELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:KNEBL KOHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-558-3608
Mailing Address - Street 1:1112 OAKENCROFT CT
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-8727
Mailing Address - Country:US
Mailing Address - Phone:336-608-4060
Mailing Address - Fax:
Practice Address - Street 1:755 HIGHLAND OAKS DR
Practice Address - Street 2:SUITE 202
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7106
Practice Address - Country:US
Practice Address - Phone:336-608-4060
Practice Address - Fax:336-665-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty