Provider Demographics
NPI:1215613872
Name:PSYCHOLOGY SOUTH, PLLC
Entity type:Organization
Organization Name:PSYCHOLOGY SOUTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SECREST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-608-2142
Mailing Address - Street 1:4 SOURWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MILLS RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:28759-1960
Mailing Address - Country:US
Mailing Address - Phone:704-608-2142
Mailing Address - Fax:
Practice Address - Street 1:4 SOURWOOD DR
Practice Address - Street 2:
Practice Address - City:MILLS RIVER
Practice Address - State:NC
Practice Address - Zip Code:28759-1960
Practice Address - Country:US
Practice Address - Phone:704-608-2142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1710120738OtherPSYCHOLOGIST