Provider Demographics
NPI:1548403561
Name:BETH BREARLEY PARKER, PHD PA
Entity Type:Organization
Organization Name:BETH BREARLEY PARKER, PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BREARLEY-PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-556-7645
Mailing Address - Street 1:3335 KNOB HILL CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-6407
Mailing Address - Country:US
Mailing Address - Phone:704-556-7645
Mailing Address - Fax:
Practice Address - Street 1:3335 KNOB HILL CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-6407
Practice Address - Country:US
Practice Address - Phone:704-556-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0343251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2815550Medicare UPIN