Provider Demographics
NPI:1518184027
Name:COMMUNITY INTERVENTION CENTER, INC
Entity Type:Organization
Organization Name:COMMUNITY INTERVENTION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:GORHAM
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-321-7710
Mailing Address - Street 1:PO BOX 30196
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0196
Mailing Address - Country:US
Mailing Address - Phone:252-321-7710
Mailing Address - Fax:252-317-0516
Practice Address - Street 1:605 LYNNDALE CT STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5449
Practice Address - Country:US
Practice Address - Phone:252-321-7710
Practice Address - Fax:252-317-0516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YP2500X, 106H00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty