1124760863 NPI number — INNATE RESILIENCE PSYCHOTHERAPY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124760863 NPI number — INNATE RESILIENCE PSYCHOTHERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNATE RESILIENCE PSYCHOTHERAPY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124760863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1818 MARTIN LUTHER KING JR BLVD # 331
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27514-7415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-446-5352
Provider Business Mailing Address Fax Number:
919-808-4334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 JONES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBOROUGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-446-5352
Provider Business Practice Location Address Fax Number:
919-808-4334
Provider Enumeration Date:
04/12/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WILLARD
Authorized Official First Name:
ALEXANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-446-5352

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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