Provider Demographics
NPI:1730581141
Name:LIASION OUTPATIENT COMPLEX LLC
Entity type:Organization
Organization Name:LIASION OUTPATIENT COMPLEX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IVY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-264-5450
Mailing Address - Street 1:PO BOX 31062
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-1062
Mailing Address - Country:US
Mailing Address - Phone:919-264-5450
Mailing Address - Fax:252-689-6029
Practice Address - Street 1:105 EASTBROOK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-4216
Practice Address - Country:US
Practice Address - Phone:252-916-1233
Practice Address - Fax:252-689-6029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health