Provider Demographics
NPI:1376678847
Name:CCDP INC
Entity Type:Organization
Organization Name:CCDP INC
Other - Org Name:COASTAL CHILDREN'S DEVELOPMENTAL PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-638-9046
Mailing Address - Street 1:1900 US HIGHWAY 70 E STE C
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-6818
Mailing Address - Country:US
Mailing Address - Phone:252-638-9046
Mailing Address - Fax:252-638-9026
Practice Address - Street 1:6209 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-9478
Practice Address - Country:US
Practice Address - Phone:252-638-5735
Practice Address - Fax:252-638-5735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-025-183322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL025183OtherLICENSE NUMBER
NC011207OtherFACILITY ID