Provider Demographics
NPI:1770561193
Name:CAROLINA PSYCHOLOGICAL AND PSYCHIATRIC HEALTH SRVS, PA
Entity type:Organization
Organization Name:CAROLINA PSYCHOLOGICAL AND PSYCHIATRIC HEALTH SRVS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:EWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-347-3010
Mailing Address - Street 1:1703 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6006
Mailing Address - Country:US
Mailing Address - Phone:910-347-3010
Mailing Address - Fax:910-347-3201
Practice Address - Street 1:1703 COUNTRY CLUB RD STE 204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6098
Practice Address - Country:US
Practice Address - Phone:910-347-3010
Practice Address - Fax:910-347-6137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0296JOtherBC/BS
NC6005337Medicaid
NC890296JMedicaid
NC2819771Medicare ID - Type Unspecified
NC0296JOtherBC/BS