Provider Demographics
NPI:1265997407
Name:CAROLINA PSYCHOLOGY GROUP, PLLC
Entity type:Organization
Organization Name:CAROLINA PSYCHOLOGY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:BEMISS
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:336-276-1278
Mailing Address - Street 1:100 S MARSHALL ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2843
Mailing Address - Country:US
Mailing Address - Phone:336-276-1278
Mailing Address - Fax:336-276-1516
Practice Address - Street 1:100 S MARSHALL ST STE 1
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2843
Practice Address - Country:US
Practice Address - Phone:336-276-1278
Practice Address - Fax:336-276-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty