Provider Demographics
NPI:1700385507
Name:PEDIATRIC AND FAMILY BEHAVIORAL HEALTH, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC AND FAMILY BEHAVIORAL HEALTH, PLLC
Other - Org Name:OASIS BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISBETH
Authorized Official - Middle Name:IVELISSE
Authorized Official - Last Name:LEGER DE BETANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-764-1818
Mailing Address - Street 1:1111 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5834
Mailing Address - Country:US
Mailing Address - Phone:704-764-1818
Mailing Address - Fax:704-285-2222
Practice Address - Street 1:1111 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5834
Practice Address - Country:US
Practice Address - Phone:704-764-1818
Practice Address - Fax:704-285-2222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 363A00000X, 363LP0808X
NC2012-015132084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1700385507OtherNPI