Provider Demographics
NPI:1518012186
Name:EASTERN PSYCHIATRIC & BEHAVIORAL SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:EASTERN PSYCHIATRIC & BEHAVIORAL SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:C
Authorized Official - Last Name:DESOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-756-4899
Mailing Address - Street 1:925 CONFERENCE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5971
Mailing Address - Country:US
Mailing Address - Phone:252-756-4899
Mailing Address - Fax:252-756-5141
Practice Address - Street 1:925 CONFERENCE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5971
Practice Address - Country:US
Practice Address - Phone:252-756-4899
Practice Address - Fax:252-756-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012MUOtherBCBS GROUP NUMBER
NC89012MUMedicaid