Provider Demographics
NPI:1720099385
Name:PSYCARE OF THE TRIAD, LLP
Entity Type:Organization
Organization Name:PSYCARE OF THE TRIAD, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBOREA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINFREY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-682-7432
Mailing Address - Street 1:661 HARTMAN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-7126
Mailing Address - Country:US
Mailing Address - Phone:336-413-3026
Mailing Address - Fax:336-413-3026
Practice Address - Street 1:661 HARTMAN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-7126
Practice Address - Country:US
Practice Address - Phone:336-413-3026
Practice Address - Fax:336-413-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301783HMedicaid
NC600568Medicaid
NC8301783GMedicaid
NC6005108Medicaid
NC8301783BMedicaid
NC02884OtherBCBS
NC6005108Medicaid