1316310576 NPI number — CAROLINA COUNSELING WELLNESS ASSOCIATES

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 1316310576 NPI number — CAROLINA COUNSELING WELLNESS ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA COUNSELING WELLNESS ASSOCIATES
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:
1316310576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2006 MOUNTAIN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APEX
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27502-3692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-410-3852
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1143 EXECUTIVE CIR
Provider Second Line Business Practice Location Address:
BLDG B STE 201
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27511-4571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-410-3852
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WEATHERHEAD
Authorized Official First Name:
JACLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
COUNSELOR
Authorized Official Telephone Number:
919-410-3852

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  11428 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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