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?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology PractitionerGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC03411OtherBCBS
NC3403406Medicaid