Provider Demographics
NPI:1588942239
Name:STATEWIDE MENTAL HEALTH & DISABILITY SERVICES PLLC
Entity type:Organization
Organization Name:STATEWIDE MENTAL HEALTH & DISABILITY SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-308-1247
Mailing Address - Street 1:730 ROANOKE AVENUE
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-2740
Mailing Address - Country:US
Mailing Address - Phone:252-308-1247
Mailing Address - Fax:252-308-1248
Practice Address - Street 1:622 ROANOKE AVE STE A
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-2740
Practice Address - Country:US
Practice Address - Phone:252-308-1247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCOO3950251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003794Medicaid