Provider Demographics
NPI:1528091972
Name:WATERSIDE THERAPY ASSOCIATES, P.L.L.C.
Entity type:Organization
Organization Name:WATERSIDE THERAPY ASSOCIATES, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:BOYETTE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:252-944-6076
Mailing Address - Street 1:110 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-2462
Mailing Address - Country:US
Mailing Address - Phone:252-944-6076
Mailing Address - Fax:252-923-0111
Practice Address - Street 1:110 BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2462
Practice Address - Country:US
Practice Address - Phone:252-944-6076
Practice Address - Fax:252-923-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5036101YM0800X
NCC0029611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10894OtherBCBS
NC6003548Medicaid
NC6102939Medicaid
NC24392-2143OtherTRICARE
NC235086OtherMHN
NC14144OtherBCBS
NC24392-2143OtherTRICARE