Provider Demographics
NPI:1194005256
Name:DREAM PROVIDER CARE SERVICES
Entity type:Organization
Organization Name:DREAM PROVIDER CARE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER.
Authorized Official - Prefix:
Authorized Official - First Name:WENDEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-946-0585
Mailing Address - Street 1:216 STEWART PKWY
Mailing Address - Street 2:DREAM PROVIDER CARE SERVICES, INC.
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4972
Mailing Address - Country:US
Mailing Address - Phone:252-946-0585
Mailing Address - Fax:252-946-0580
Practice Address - Street 1:703 N BROAD STREET
Practice Address - Street 2:DREAM PROVIDER CARE SERVICES
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-0703
Practice Address - Country:US
Practice Address - Phone:252-946-0585
Practice Address - Fax:252-946-0580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 1041C0700X
NCMHL007036251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005782Medicaid