Basic Information
| Provider Information | |||||||||
| NPI: | 1396802914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON COUNTY PSYCHOLOGICAL SERVICES PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HAYWOOD COUNTY PSYCHOLOGICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 728 | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287790728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285862311 | ||||||||
| FaxNumber: | 8285865450 | ||||||||
| Practice Location | |||||||||
| Address1: | 98D COPE CREEK RD | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287799508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285862311 | ||||||||
| FaxNumber: | 8285865450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOUTHIT | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8285862311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103TC2200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 104100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251S00000X | N | Agencies | Community/Behavioral Health | 101YP2500X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 017UF | 01 | NC | BCBS PROVIDER # | OTHER | 8302150 | 05 | NC | MEDICAID | 6005078 | 05 | NC | MEDICAID | 8300532 | 05 | NC | MEDICAID |