Provider Demographics
NPI:1336283837
Name:MARVIN D. COULTHARD
Entity Type:Organization
Organization Name:MARVIN D. COULTHARD
Other - Org Name:TAR RIVER PSYCHOLOGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COULTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPA
Authorized Official - Phone:252-823-2927
Mailing Address - Street 1:325 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-5009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-5009
Practice Address - Country:US
Practice Address - Phone:252-823-2927
Practice Address - Fax:252-823-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1118101YA0400X
NC4630101YM0800X
NC4058101YP2500X
NC0734103T00000X
NCC000554104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005951Medicaid
NC131UROtherBLUECROSSBLUESHIELD