Provider Demographics
NPI:1548332703
Name:NORTHEASTERN CLINICAL SERVICES INC
Entity type:Organization
Organization Name:NORTHEASTERN CLINICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST
Authorized Official - Phone:252-332-1610
Mailing Address - Street 1:PO BOX 291
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-0291
Mailing Address - Country:US
Mailing Address - Phone:252-794-1255
Mailing Address - Fax:252-794-1356
Practice Address - Street 1:103 DUNDEE ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-6702
Practice Address - Country:US
Practice Address - Phone:252-794-1255
Practice Address - Fax:252-794-1356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2526251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107194Medicaid