Provider Demographics
NPI:1407090707
Name:SOUTHEAST PSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:SOUTHEAST PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:H
Authorized Official - Last Name:IYOOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-552-0116
Mailing Address - Street 1:6115 PARK SOUTH DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3269
Mailing Address - Country:US
Mailing Address - Phone:704-552-0116
Mailing Address - Fax:704-552-7550
Practice Address - Street 1:8840 BLAKENEY PROFESSIONAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6718
Practice Address - Country:US
Practice Address - Phone:704-552-0116
Practice Address - Fax:704-552-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5021103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005111Medicaid
NC6005111Medicaid