Provider Demographics
NPI:1457745697
Name:EASTER SEALS UCP
Entity Type:Organization
Organization Name:EASTER SEALS UCP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUBSTANCE ABUSE
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS-A
Authorized Official - Phone:919-274-8356
Mailing Address - Street 1:4038 CAPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3123
Mailing Address - Country:US
Mailing Address - Phone:252-467-2860
Mailing Address - Fax:
Practice Address - Street 1:4038 CAPITAL DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3123
Practice Address - Country:US
Practice Address - Phone:252-467-2860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty