Provider Demographics
NPI:1417017963
Name:WILSON GREENE MENTAL HEALTH
Entity Type:Organization
Organization Name:WILSON GREENE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:RACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-937-8141
Mailing Address - Street 1:1709 TARBORO ST SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3428
Mailing Address - Country:US
Mailing Address - Phone:252-399-8021
Mailing Address - Fax:
Practice Address - Street 1:1709 TARBORO ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901818OtherPHYSICIAN GROUP NUMBER
NC6005615OtherMULTI-SPECIALTY NUMBER
NC5901738Medicaid
NC3408391Medicaid
NC07196OtherBLUE CROSS
NC3404936OtherBILLING PROVIDER NUMBER
NC8301342Medicaid
NC8301342GMedicaid