Provider Demographics
NPI:1952301079
Name:SOUTHEASTERN PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER-LINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-682-6718
Mailing Address - Street 1:302 N MAIN ST
Mailing Address - Street 2:PO BOX 369
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-1730
Mailing Address - Country:US
Mailing Address - Phone:910-628-6718
Mailing Address - Fax:910-628-6719
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1730
Practice Address - Country:US
Practice Address - Phone:910-628-6718
Practice Address - Fax:910-628-6719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0384MOtherBCBS
NC6005435Medicaid
NC1318HOtherBCBS
NC6005435Medicaid