Provider Demographics
NPI:1285857433
Name:SOUTHERN PSYCHOLOGY P A
Entity Type:Organization
Organization Name:SOUTHERN PSYCHOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:V
Authorized Official - Last Name:RALEIGH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MPH
Authorized Official - Phone:919-419-0900
Mailing Address - Street 1:3500 WESTGATE DR
Mailing Address - Street 2:SUITE 601
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2567
Mailing Address - Country:US
Mailing Address - Phone:919-419-0900
Mailing Address - Fax:919-419-0991
Practice Address - Street 1:3500 WESTGATE DR
Practice Address - Street 2:SUITE 601
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2567
Practice Address - Country:US
Practice Address - Phone:919-419-0900
Practice Address - Fax:919-419-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3032261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2823562CMedicare PIN