Provider Demographics
NPI:1689817223
Name:SOUTHEASTERN REGIONAL MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MENTAL HEALTH
Other - Org Name:WALK-IN CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-272-1217
Mailing Address - Street 1:450 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-9494
Mailing Address - Country:US
Mailing Address - Phone:910-738-5261
Mailing Address - Fax:910-738-8230
Practice Address - Street 1:207 W 29TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2901
Practice Address - Country:US
Practice Address - Phone:910-618-5606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901282Medicaid