Provider Demographics
NPI:1821395674
Name:EXTENDED REACH DAYTREATMENT FOR CHILDREN AND ADOLESCENTS
Entity Type:Organization
Organization Name:EXTENDED REACH DAYTREATMENT FOR CHILDREN AND ADOLESCENTS
Other - Org Name:EXTENDED REACH DAY TREATMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:BOATMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-229-8256
Mailing Address - Street 1:302 BRADFORD AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5406
Mailing Address - Country:US
Mailing Address - Phone:910-484-0095
Mailing Address - Fax:919-238-7287
Practice Address - Street 1:302 BRADFORD AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5406
Practice Address - Country:US
Practice Address - Phone:910-484-0095
Practice Address - Fax:919-238-7287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-852251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302981Medicaid
NC8302339Medicaid
NC3410184Medicaid
NC6006927Medicaid