Provider Demographics
NPI:1336292556
Name:TRIAD BEHAVIORAL RESOURCES PC
Entity Type:Organization
Organization Name:TRIAD BEHAVIORAL RESOURCES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-765-1003
Mailing Address - Street 1:12 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4537
Mailing Address - Country:US
Mailing Address - Phone:910-765-1003
Mailing Address - Fax:910-765-1004
Practice Address - Street 1:12 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4537
Practice Address - Country:US
Practice Address - Phone:910-765-1003
Practice Address - Fax:910-765-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL041686101YM0800X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005083Medicaid
NC017U3OtherBLUE CROSS BLUE SHIELD