| Triad Behavioral Resources Pc | |
|
12 N 5th Ave Wilmington NC 28401-4537 | |
| (910) 765-1003 | |
| (910) 765-1004 |
| Full Name | Triad Behavioral Resources Pc |
|---|---|
| Speciality | Family Medicine |
| Location | 12 N 5th Ave, Wilmington, North Carolina |
| Authorized Official Name and Position | David Bolton (CEO) |
| Authorized Official Contact | 9107651003 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Triad Behavioral Resources Pc 12 N 5th Ave Wilmington NC 28401-4537 Ph: (910) 765-1003 | Triad Behavioral Resources Pc 12 N 5th Ave Wilmington NC 28401-4537 Ph: (910) 765-1003 |
| NPI Number | 1336292556 |
|---|---|
| Provider Enumeration Date | 01/19/2007 |
| Last Update Date | 09/28/2023 |
| Certification Date | 09/28/2023 |
| Medicare PECOS PAC ID | 7911316435 |
|---|---|
| Medicare Enrollment ID | O20210512002113 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336292556 | NPI | - | NPPES |
| 6005083 | Medicaid | NC | |
| 017U3 | Other | NC | BLUE CROSS BLUE SHIELD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | MHL041686 (North Carolina) | Secondary |
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | David Owens |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1932284833 PECOS PAC ID: 4284546987 Enrollment ID: I20050428000186 |
| Provider Name | Valerie Idada Parker |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1770736092 PECOS PAC ID: 8527254580 Enrollment ID: I20101202000407 |
| Provider Name | Wendy D Smith |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1033447156 PECOS PAC ID: 4981838828 Enrollment ID: I20131009000884 |
| Provider Name | Nicolee Knowles |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1386110716 PECOS PAC ID: 7719316397 Enrollment ID: I20200402000714 |
| Provider Name | Princess P Minter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1073270500 PECOS PAC ID: 0648651703 Enrollment ID: I20220720002270 |
| Provider Name | Jaime Snyder |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962844902 PECOS PAC ID: 8921232737 Enrollment ID: I20230131002628 |
| Provider Name | Miranda Lynn Slater |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1245616259 PECOS PAC ID: 8921442179 Enrollment ID: I20240215004001 |
| Provider Name | David James Bolton |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1427101617 PECOS PAC ID: 3476874959 Enrollment ID: I20240221000014 |
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