Basic Information
| Provider Information | |||||||||
| NPI: | 1366876054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SERVIS | ||||||||
| FirstName: | BETSY | ||||||||
| MiddleName: | CLAYTON | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 W DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | MOCKSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270282327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367515636 | ||||||||
| FaxNumber: | 3367515696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 10068 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 186CV | 01 | NC | BCBS | OTHER | 601111-248 | 01 | NC | MAGELLAN | OTHER | 1336876054 | 05 | NC | MEDICAID | 1336876054 | 01 | NC | UBH/OPTUM | OTHER | 1336876054 | 01 | NC | HUMANA | OTHER |