Provider Demographics
NPI: | 1760507990 |
---|---|
Name: | EAST CAROLINA UNIVERSITY |
Entity Type: | Organization |
Organization Name: | EAST CAROLINA UNIVERSITY |
Other - Org Name: | CHILDREN'S DEVELOPMENTAL SERVICES AGENCY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DIRECTOR COSA |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | GARY |
Authorized Official - Middle Name: | JUDSON |
Authorized Official - Last Name: | STAINBACK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHD |
Authorized Official - Phone: | 252-737-1167 |
Mailing Address - Street 1: | IRONS BUILDING-OGLESBY DR. |
Mailing Address - Street 2: | |
Mailing Address - City: | GREENVILLE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27858 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 252-737-1177 |
Mailing Address - Fax: | 252-328-4486 |
Practice Address - Street 1: | IRONS BUILDING-OGLESBY DR. |
Practice Address - Street 2: | |
Practice Address - City: | GREENVILLE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27858 |
Practice Address - Country: | US |
Practice Address - Phone: | 252-737-1177 |
Practice Address - Fax: | 252-328-4486 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-20 |
Last Update Date: | 2008-07-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 163W00000X | Nursing Service Providers | Registered Nurse | Group - Multi-Specialty | |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
No | 2080P0006X | Allopathic & Osteopathic Physicians | Pediatrics | Developmental - Behavioral Pediatrics | Group - Multi-Specialty |
No | 2080P0008X | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | Group - Multi-Specialty |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225CA2400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | Assistive Technology Practitioner | Group - Multi-Specialty |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist | Group - Multi-Specialty | |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 03411 | Other | BCBS |
NC | 3403406 | Medicaid |