Provider Demographics
NPI:1619659026
Name:FOOTHILLS BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:FOOTHILLS BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:336-303-0585
Mailing Address - Street 1:122 N CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27011-8934
Mailing Address - Country:US
Mailing Address - Phone:336-303-0585
Mailing Address - Fax:
Practice Address - Street 1:122 N CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27011-8934
Practice Address - Country:US
Practice Address - Phone:336-303-0585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-04
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1689159196Medicaid