Provider Demographics
NPI:1396984480
Name:CAROLINA PROFESSIONAL MENTAL HEALTH
Entity type:Organization
Organization Name:CAROLINA PROFESSIONAL MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:HODGE
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:PLCSW
Authorized Official - Phone:910-272-9356
Mailing Address - Street 1:109 N COURT SQ
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-5554
Mailing Address - Country:US
Mailing Address - Phone:910-272-9356
Mailing Address - Fax:910-735-1945
Practice Address - Street 1:109 N COURT SQ
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-5554
Practice Address - Country:US
Practice Address - Phone:910-272-9356
Practice Address - Fax:910-735-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0801X261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCSR001844Medicaid