Provider Demographics
NPI:1760172555
Name:DEEP RIVER PSYCHIATRIC GROUP PLLC
Entity Type:Organization
Organization Name:DEEP RIVER PSYCHIATRIC GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAIRCLOTH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, RN
Authorized Official - Phone:919-630-5144
Mailing Address - Street 1:301 KING ST APT 1E
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-1699
Mailing Address - Country:US
Mailing Address - Phone:919-630-5144
Mailing Address - Fax:
Practice Address - Street 1:301 KING ST APT 1E
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-1699
Practice Address - Country:US
Practice Address - Phone:919-630-5144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1457876591OtherMEDICARE
NC1457876571Medicaid