Provider Demographics
NPI:1891865218
Name:CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC
Entity Type:Organization
Organization Name:CHRYSALIS CENTER FOR COUNSELING AND EATING DISORDER TREATMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROFESSIONAL RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-790-9500
Mailing Address - Street 1:3240 BURNT MILL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2576
Mailing Address - Country:US
Mailing Address - Phone:910-790-9500
Mailing Address - Fax:910-796-8111
Practice Address - Street 1:3904 OLEANDER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6717
Practice Address - Country:US
Practice Address - Phone:910-790-9500
Practice Address - Fax:910-796-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2805103T00000X
NCLPC6828103TC1900X
NCC0064341041C0700X
NCL003399133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC355080OtherMHN/TRICARE
NC018AMOtherBCBS
NC6006162Medicaid
NC2347863Medicare PIN