Provider Demographics
NPI:1194877357
Name:SIXTH AVENUE PSYCHIATRIC REHABILITATION PARTNERS
Entity type:Organization
Organization Name:SIXTH AVENUE PSYCHIATRIC REHABILITATION PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-697-1581
Mailing Address - Street 1:714 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28739-4114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:527 N JUSTICE ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739-4217
Practice Address - Country:US
Practice Address - Phone:828-697-9765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301703Medicaid