Provider Demographics
NPI:1508190067
Name:CROSSROADS SEXUAL ASSAULT RESPONSE & RESOURCE CENTER INC
Entity Type:Organization
Organization Name:CROSSROADS SEXUAL ASSAULT RESPONSE & RESOURCE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAGELE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:336-228-0813
Mailing Address - Street 1:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27216-0673
Mailing Address - Country:US
Mailing Address - Phone:336-228-0813
Mailing Address - Fax:336-228-7087
Practice Address - Street 1:1206 VAUGHN RD
Practice Address - Street 2:SUITE B
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2847
Practice Address - Country:US
Practice Address - Phone:336-228-0813
Practice Address - Fax:336-228-7087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6879101YP2500X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912904Medicaid