Provider Demographics
NPI:1811058803
Name:RANDOLPH JUVENILE DAY REPORTING CENTER
Entity type:Organization
Organization Name:RANDOLPH JUVENILE DAY REPORTING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THURMAN
Authorized Official - Last Name:MORRISSETT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:336-683-8228
Mailing Address - Street 1:1520 N FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-3894
Mailing Address - Country:US
Mailing Address - Phone:336-683-8228
Mailing Address - Fax:336-683-8217
Practice Address - Street 1:1520 N FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-3894
Practice Address - Country:US
Practice Address - Phone:336-683-8228
Practice Address - Fax:336-683-8217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-076-030251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health