Provider Demographics
NPI:1730131863
Name:CAROLINA PSYCH GROUP, PA
Entity Type:Organization
Organization Name:CAROLINA PSYCH GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:704-873-1697
Mailing Address - Street 1:515 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4107
Mailing Address - Country:US
Mailing Address - Phone:704-873-1697
Mailing Address - Fax:
Practice Address - Street 1:515 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-873-1697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC633103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005112Medicaid