Provider Demographics
NPI:1619186970
Name:ALSTON, CHARLMAYNE SEABERRY
Entity Type:Individual
Prefix:MRS
First Name:CHARLMAYNE
Middle Name:SEABERRY
Last Name:ALSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 LITCHFORD RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-7112
Mailing Address - Country:US
Mailing Address - Phone:919-798-8638
Mailing Address - Fax:919-872-5412
Practice Address - Street 1:1733 HODGE RD
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-9588
Practice Address - Country:US
Practice Address - Phone:919-798-8638
Practice Address - Fax:919-872-5412
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL092247322D00000X
NCMHL092631320800000X
NCMHL092633320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805406Medicaid
NC7805399Medicaid