Provider Demographics
NPI:1851694814
Name:NEXT LEVEL ADOLESCENT SERVICES, INC.
Entity Type:Organization
Organization Name:NEXT LEVEL ADOLESCENT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENTIERS
Authorized Official - Middle Name:ANTARIO
Authorized Official - Last Name:LONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-634-2211
Mailing Address - Street 1:1107 HOLLOWAY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3852
Mailing Address - Country:US
Mailing Address - Phone:919-683-6398
Mailing Address - Fax:
Practice Address - Street 1:1107 HOLLOWAY ST
Practice Address - Street 2:SUITE NUMBER 100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3852
Practice Address - Country:US
Practice Address - Phone:919-683-6398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL032446251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302350Medicaid
NC6008000Medicaid
NC5915653Medicaid