Provider Demographics
NPI:1518211309
Name:PORT CITY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PORT CITY BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:CREECH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-799-4505
Mailing Address - Street 1:1606 WELLINGTON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7704
Mailing Address - Country:US
Mailing Address - Phone:910-799-4505
Mailing Address - Fax:910-799-4345
Practice Address - Street 1:1606 WELLINGTON AVE STE A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7704
Practice Address - Country:US
Practice Address - Phone:910-799-4505
Practice Address - Fax:910-799-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID# FOR GRP