Provider Demographics
NPI:1285867952
Name:MOOD TREATMENT CENTER, PLLC
Entity Type:Organization
Organization Name:MOOD TREATMENT CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED USER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:BRUNS
Authorized Official - Last Name:AIKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-722-7266
Mailing Address - Street 1:713 S MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5808
Mailing Address - Country:US
Mailing Address - Phone:336-722-7266
Mailing Address - Fax:336-201-0538
Practice Address - Street 1:1615 POLO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3859
Practice Address - Country:US
Practice Address - Phone:336-722-7266
Practice Address - Fax:336-201-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001009962084P0800X
NC100934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty