Provider Demographics
NPI:1578986931
Name:SMEG FAMILY MENTAL HEALTH
Entity Type:Organization
Organization Name:SMEG FAMILY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:252-364-8972
Mailing Address - Street 1:610A OLD TAR VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7936
Mailing Address - Country:US
Mailing Address - Phone:252-364-8972
Mailing Address - Fax:252-364-8971
Practice Address - Street 1:610A OLD TAR VILLAGE RD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-7936
Practice Address - Country:US
Practice Address - Phone:252-364-8972
Practice Address - Fax:252-364-8971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003235163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6113048Medicaid