Provider Demographics
NPI:1285671602
Name:TRIAD PSYCHIATRIC AND COUNSELING CENTER PA
Entity type:Organization
Organization Name:TRIAD PSYCHIATRIC AND COUNSELING CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-632-3505
Mailing Address - Street 1:603 DOLLEY MADISON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-4283
Mailing Address - Country:US
Mailing Address - Phone:336-632-3505
Mailing Address - Fax:336-632-3503
Practice Address - Street 1:603 DOLLEY MADISON RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4282
Practice Address - Country:US
Practice Address - Phone:336-632-3505
Practice Address - Fax:336-632-3503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2270101Y00000X
1041C0700X
NC384152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890283KMedicaid
NC2314299Medicare ID - Type Unspecified