Provider Demographics
NPI:1861677908
Name:UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
Other - Org Name:SUNRISE DIAGNOSTIC ASSESSMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:RENZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-966-9803
Mailing Address - Street 1:104 AIRPORT DR CB 1270
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-5023
Mailing Address - Country:US
Mailing Address - Phone:919-966-9803
Mailing Address - Fax:
Practice Address - Street 1:209 CONNOR DR
Practice Address - Street 2:UNIT 17
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514
Practice Address - Country:US
Practice Address - Phone:919-960-3775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-08
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-068-114251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300699GMedicaid