MEDICARE: SQUARE ONE WELLNESS CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	1041C0700X	Clinical Social Worker
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1467525873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SQUARE ONE WELLNESS CENTER, INC.

Provider Business Mailing Address
First Line	:	1804 MARTIN LUTHER KING PKWY STE 111
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-3587
Country	:	US
Telephone Number	:	704-956-3062
Fax Number	:

Provider Business Practice Location Address
First Line	:	1804 MARTIN LUTHER KING PKWY STE 111
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-3587
Country	:	US
Telephone Number	:	704-956-3062
Fax Number	:

Authorized Official
Title or Position	:	ED
Name	:	MR. DEMETRIUS CRAYTON
Credential	:	B.A.
Telephone Number	:	704-956-3062

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	03/08/2017

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