Provider Demographics
NPI:1134424542
Name:OUR TREATMENT CENTER
Entity type:Organization
Organization Name:OUR TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND-KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:919-601-1313
Mailing Address - Street 1:1702 SHERIFF WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-6720
Mailing Address - Country:US
Mailing Address - Phone:919-601-1313
Mailing Address - Fax:919-267-9079
Practice Address - Street 1:4909 WATERS EDGE DR
Practice Address - Street 2:104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-2462
Practice Address - Country:US
Practice Address - Phone:919-601-1313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 101YM0800X
NC7134101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008508Medicaid