Provider Demographics
NPI:1821130642
Name:CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC
Entity Type:Organization
Organization Name:CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-933-0828
Mailing Address - Street 1:101 E WEAVER ST
Mailing Address - Street 2:SUITE G-7
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-2370
Mailing Address - Country:US
Mailing Address - Phone:919-933-0770
Mailing Address - Fax:919-933-0767
Practice Address - Street 1:815 SANFORD RD
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-9423
Practice Address - Country:US
Practice Address - Phone:919-542-7432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-019-024251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301147Medicaid
NC8301147SMedicaid