Basic Information
| Provider Information | |||||||||
| NPI: | 1407964174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DUKE UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHILD DEVELOPMENT & BEHAVIORAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 110566 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277095566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204855 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 402 TRENT DR | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196848111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 10/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE DEAN ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9196848111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 6005177 | 05 | NC | MEDICAID | 01446 | 01 | NC | BCBS | OTHER |