Provider Demographics
NPI:1356362446
Name:DAVIDSON COUNTY PUBLIC SCHOOLS SUPE
Entity type:Organization
Organization Name:DAVIDSON COUNTY PUBLIC SCHOOLS SUPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RELATED SERVICES COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-242-5516
Mailing Address - Street 1:PO BOX 2057
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27293-2057
Mailing Address - Country:US
Mailing Address - Phone:336-249-8182
Mailing Address - Fax:336-249-8009
Practice Address - Street 1:218 COUNTY SCHOOL RD STE C
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-5768
Practice Address - Country:US
Practice Address - Phone:336-242-5508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8600122Medicaid