Provider Demographics
NPI:1982783049
Name:WTB NEW VISION INC.
Entity Type:Organization
Organization Name:WTB NEW VISION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-723-7707
Mailing Address - Street 1:102 W 3RD ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3987
Mailing Address - Country:US
Mailing Address - Phone:336-723-7707
Mailing Address - Fax:336-723-7708
Practice Address - Street 1:102 W 3RD ST
Practice Address - Street 2:SUITE 502
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3940
Practice Address - Country:US
Practice Address - Phone:336-723-7707
Practice Address - Fax:336-723-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCMHL-034-170322D00000X
NCMHL-034-185322D00000X
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
NC6603924Medicaid
NC8300791Medicaid
NC8300791BMedicaid
NC6603536Medicaid
NC6604170Medicaid
NC8300791GMedicaid