Provider Demographics
NPI:1730240714
Name:APPALACHIAN STATE UNIVERSITY
Entity type:Organization
Organization Name:APPALACHIAN STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:828-433-7176
Mailing Address - Street 1:203 AVERY AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-3102
Mailing Address - Country:US
Mailing Address - Phone:828-433-7176
Mailing Address - Fax:828-437-8329
Practice Address - Street 1:203 AVERY AVE
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-3102
Practice Address - Country:US
Practice Address - Phone:828-433-7176
Practice Address - Fax:828-437-8329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
NC322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300145KMedicaid
NC8300145Medicaid