Provider Demographics
NPI:1891193918
Name:CAROLINA BEHAVIORAL MEDICINE, PA
Entity Type:Organization
Organization Name:CAROLINA BEHAVIORAL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CAULEY
Authorized Official - Last Name:KENNERLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-659-3541
Mailing Address - Street 1:366 GEORGE W LILES PKWY NW
Mailing Address - Street 2:STE 52
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-2406
Mailing Address - Country:US
Mailing Address - Phone:704-659-3541
Mailing Address - Fax:704-706-2348
Practice Address - Street 1:1036 BRANCHVIEW DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2998
Practice Address - Country:US
Practice Address - Phone:704-659-3541
Practice Address - Fax:888-977-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-06
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4561103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty