Provider Demographics
NPI:1861838492
Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC
Entity Type:Organization
Organization Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP SERVICE LINE
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-783-8898
Mailing Address - Street 1:200 WEBB BLVD
Mailing Address - Street 2:PO BOX 629
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532-1930
Mailing Address - Country:US
Mailing Address - Phone:252-447-3892
Mailing Address - Fax:
Practice Address - Street 1:10150 MALLARD CREEK RD
Practice Address - Street 2:SUITE 510
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9708
Practice Address - Country:US
Practice Address - Phone:704-333-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200481Medicaid