Provider Demographics
NPI:1841352101
Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Entity type:Organization
Organization Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-210-7661
Mailing Address - Street 1:5171 GLENWOOD AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3266
Mailing Address - Country:US
Mailing Address - Phone:919-783-8898
Mailing Address - Fax:919-792-5486
Practice Address - Street 1:100 LOOP ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-4062
Practice Address - Country:US
Practice Address - Phone:910-596-2221
Practice Address - Fax:910-596-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300709BMedicaid
NC8300709HMedicaid
NC8300709GMedicaid
NC8300709AMedicaid
NC8300709FMedicaid
NC018KJOtherNC BCBS GROUP
NC8300709Medicaid
NC8300709IMedicaid