Provider Demographics
NPI:1942505987
Name:PHYSICIAN ALLIANCE FOR MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:PHYSICIAN ALLIANCE FOR MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:RENE'
Authorized Official - Last Name:KACZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-262-7107
Mailing Address - Street 1:PO BOX 15511
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28408-5511
Mailing Address - Country:US
Mailing Address - Phone:910-794-3929
Mailing Address - Fax:910-798-2303
Practice Address - Street 1:3208 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-0800
Practice Address - Country:US
Practice Address - Phone:910-794-3929
Practice Address - Fax:910-798-2303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3410154Medicaid