Provider Demographics
NPI:1558545806
Name:EAST COVE PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:EAST COVE PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD/ADULT PSYCHIATRIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLICKI-SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-523-2781
Mailing Address - Street 1:2901 N HERRITAGE ST STE C
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1581
Mailing Address - Country:US
Mailing Address - Phone:252-523-2781
Mailing Address - Fax:252-523-2779
Practice Address - Street 1:2901 N HERRITAGE ST STE C
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1581
Practice Address - Country:US
Practice Address - Phone:252-523-2781
Practice Address - Fax:252-523-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137CEMedicaid