Organization
LIFESOURCE OF NORTH CAROLINA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMANDA SEYMOUR (CREDENTIALING SPECIALIST)
(910) 794-4521
Entity
Organization
Contact information
Practice address
1525 EBER RD, HOLLAND, OH 43528-9616
(910) 742-9243
Mailing address
PO BOX 538622, ATLANTA, GA 30353-8622
(910) 742-9243
(888) 746-1787
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
Primary
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Enumeration date
04/14/2022
Last updated
04/10/2024
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