Provider Demographics
NPI:1780033233
Name:INTEGRATED BEHAVIORAL HEALTH MANAGEMENT
Entity Type:Organization
Organization Name:INTEGRATED BEHAVIORAL HEALTH MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-910-6142
Mailing Address - Street 1:8430 MEDICAL PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-9758
Mailing Address - Country:US
Mailing Address - Phone:704-910-6142
Mailing Address - Fax:908-422-0106
Practice Address - Street 1:8430 MEDICAL PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9758
Practice Address - Country:US
Practice Address - Phone:704-910-6142
Practice Address - Fax:980-422-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004974251B00000X, 261QM0850X, 261QM0855X, 261QP2300X
363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC1285AMedicare UPIN