Provider Demographics
NPI:1831592864
Name:AMERICORP BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:AMERICORP BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-696-6071
Mailing Address - Street 1:1320 MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3266
Mailing Address - Country:US
Mailing Address - Phone:919-696-6071
Mailing Address - Fax:
Practice Address - Street 1:304 W MILLBROOK RD STE F
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4381
Practice Address - Country:US
Practice Address - Phone:919-329-2630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-05
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC 000396101YM0800X
NCMHL-09-2503322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003085Medicaid