Provider Demographics
NPI:1902028228
Name:PERSONALIZED THERAPY, INC.
Entity Type:Organization
Organization Name:PERSONALIZED THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:252-353-4968
Mailing Address - Street 1:2317 EXECUTIVE CIR STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3762
Mailing Address - Country:US
Mailing Address - Phone:252-353-4968
Mailing Address - Fax:252-353-4967
Practice Address - Street 1:2317 EXECUTIVE CIR STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3762
Practice Address - Country:US
Practice Address - Phone:252-353-4968
Practice Address - Fax:252-353-4967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4144101YM0800X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005249Medicaid