Organization
DEEP RIVER PSYCHIATRIC GROUP PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ALLAN M FAIRCLOTH PMHNP-BC, RN (CEO)
(919) 630-5144
Entity
Organization
Contact information
Practice address
301 KING ST APT 1E, GREENSBORO, NC 27406-1699
(919) 630-5144
Mailing address
301 KING ST APT 1E, GREENSBORO, NC 27406-1699
(919) 630-5144
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1457876571
—
NC
01
—
1457876591
MEDICARE
NC
Enumeration date
05/15/2023
Last updated
05/15/2023
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