Provider Demographics
NPI:1255571410
Name:PAIN MANAGEMENT PSYCHOLOGY SERVICES, PA
Entity type:Organization
Organization Name:PAIN MANAGEMENT PSYCHOLOGY SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:NORRIS
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-770-6451
Mailing Address - Street 1:160 KIMEL FOREST DR.
Mailing Address - Street 2:STE. 100
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6084
Mailing Address - Country:US
Mailing Address - Phone:336-770-6451
Mailing Address - Fax:336-714-6475
Practice Address - Street 1:160 KIMEL FOREST DR.
Practice Address - Street 2:STE. 100
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6084
Practice Address - Country:US
Practice Address - Phone:336-770-6451
Practice Address - Fax:336-714-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0388103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006753Medicaid
616591400OtherDOL/OWCP (DEPARTMENT OF LABOR OFFICE OF WORKERS COMPENSATION PROGRAMS)