Provider Demographics
NPI:1144419979
Name:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Other - Org Name:C&A PARTIAL HOSPITALIZATION
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:GETTELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-444-2406
Mailing Address - Street 1:501 BILLINGSLEY ROAD
Mailing Address - Street 2:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1009
Mailing Address - Country:US
Mailing Address - Phone:704-358-2710
Mailing Address - Fax:704-358-2938
Practice Address - Street 1:330 BILLINGSLEY ROAD
Practice Address - Street 2:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5055
Practice Address - Country:US
Practice Address - Phone:704-444-2444
Practice Address - Fax:704-444-2464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0071261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300445DMedicaid