Provider Demographics
NPI:1366699449
Name:PIEDMONT BEHAVIORAL RESOURCES, INC.
Entity type:Organization
Organization Name:PIEDMONT BEHAVIORAL RESOURCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TANZY
Authorized Official - Middle Name:BARROW
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-487-6226
Mailing Address - Street 1:201 W. MARION ST. STE. 207
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150
Mailing Address - Country:US
Mailing Address - Phone:704-487-6226
Mailing Address - Fax:704-487-6286
Practice Address - Street 1:201 W. MARION ST. STE. 207
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150
Practice Address - Country:US
Practice Address - Phone:704-487-6226
Practice Address - Fax:704-487-6286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC229101YA0400X
NCMHL-023-148101YA0400X
NC1135101YA0400X
NC366101YA0400X
101YM0800X, 251S00000X
NC5595101YP2500X
NCMHL-023-046322D00000X
NC251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418626Medicaid
NC6604374Medicaid
NC6604390Medicaid
NC6006639Medicaid
NC6603420Medicaid
NC8302555QMedicaid
NC8302555Medicaid