Provider Demographics
NPI:1972170504
Name:UCA BEHAVIORAL SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:UCA BEHAVIORAL SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIETRIX
Authorized Official - Middle Name:
Authorized Official - Last Name:URQUHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-408-9082
Mailing Address - Street 1:74 WHITESELL WAY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-0747
Mailing Address - Country:US
Mailing Address - Phone:919-408-9082
Mailing Address - Fax:
Practice Address - Street 1:2530 MERIDIAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5273
Practice Address - Country:US
Practice Address - Phone:919-408-9082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103107Medicaid