Provider Demographics
NPI:1720414808
Name:COMMWELLHEALTH
Entity Type:Organization
Organization Name:COMMWELLHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT BEHAVIORAL HEALTH
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:STROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS, CCS
Authorized Official - Phone:910-567-6194
Mailing Address - Street 1:3331 EASY ST
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-7988
Mailing Address - Country:US
Mailing Address - Phone:910-567-6194
Mailing Address - Fax:
Practice Address - Street 1:3331 EASY ST
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-7988
Practice Address - Country:US
Practice Address - Phone:910-567-6194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2211302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101YAO4008Medicaid