Provider Demographics
NPI:1396256426
Name:GARDEN VILLAGE PSYCHIATRIC AND COUNSELING SERVICES PLLC
Entity type:Organization
Organization Name:GARDEN VILLAGE PSYCHIATRIC AND COUNSELING SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:CAMILLE ONEAL
Authorized Official - Last Name:BREWINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:336-282-1251
Mailing Address - Street 1:3703 W MARKET ST STE A
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1300
Mailing Address - Country:US
Mailing Address - Phone:336-282-1251
Mailing Address - Fax:336-282-1252
Practice Address - Street 1:3703 W MARKET ST STE A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1300
Practice Address - Country:US
Practice Address - Phone:336-282-1251
Practice Address - Fax:336-282-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201644363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1912033689Medicaid
NC1538183447Medicaid