Provider Demographics
NPI:1356517536
Name:PSYCLINC
Entity type:Organization
Organization Name:PSYCLINC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BUSINESS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:REAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-530-0850
Mailing Address - Street 1:518 S ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-2735
Mailing Address - Country:US
Mailing Address - Phone:704-530-0850
Mailing Address - Fax:704-735-9810
Practice Address - Street 1:518 S ASPEN ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-2735
Practice Address - Country:US
Practice Address - Phone:704-530-0850
Practice Address - Fax:704-735-9810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3163OtherLICENSE
NC6000865Medicaid
NC6006696Medicaid
NC6000865Medicaid