Basic Information
Provider Information | |||||||||
NPI: | 1760528939 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DUKE UNIVERSITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EATING DISORDERS CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 110566 | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277095566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9196204855 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 TRENT DR | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277100001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9196848111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2007 | ||||||||
LastUpdateDate: | 10/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIBSON | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | SCOTT | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE DEAN ADMINISTRATION | ||||||||
AuthorizedOfficialTelephone: | 9196843945 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   | 1041C0700X |   | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103T00000X |   | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 013X2 | 01 | NC | BCBS NON PAR | OTHER |